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Hello, good evening everyone. Welcome back to our session. Three of the Mind, the Bleep I MG series. We are conducting this plateau marks. Um Thank you for everyone who has attended our previous sessions and welcome to those whose first attending the session. So um just a quick introduction about this plateau marks, we'll be running through um some teaching in the beginning of the sessions and then we'll have three mos which is tailored to our pla two exam. So um anyone who would like to be volunteers, it will be much appreciated and we will give some feedbacks at the end of every stations. So just a quick introduction. My name is Dennis. I'm currently in F ones um working in the ports of General Hospital having passed my plaque to last year. So I was quite lucky to pass all my stations. So um I've done a lot of mocks for other people as well. Hence I feel like I feel like I need to share this experience with everyone uh with me. I've got Amanda. Would you like to introduce yourself? Yes, hi. Um Good evening everyone. Uh My name is Amanda. I'm, I'm uh So II work as a junior doctor, uh, at an F two grade. I work at Stepping Hill, um, in Manchester. Um, I passed my blood to about a year and a half ago. So it's been a while. Um, and I, I think I missed maybe two stations, so I'm not, maybe as good as Dennis, but we'll try to do a good job today trying to give you an idea, uh, of a mock idea of what the exam would be like. Um I think I'm gonna be most, I'm gonna be a patient for most of your stations and I think Dennis will leave with the teaching. Ok? And we have got our I MG lead for Mind Raza there in the background with us as our facilitator. All right. So just a OK. She's no, it's fine. Continue. I'm just here in the background. Um If anyone would love to volunteer, please uh send messages in the chat. Um And I'll add you to the uh I'll invite you to the stage. Um As soon as we, we start doing cases. Thank you. All right. So just a quick run through and just an overview of what we're gonna do tonight. I will be discussing most mainly about semen where most people struggle because I do struggle with the stations as well. Um Be the main reason is time management where there are eight minutes and we struggle to finish everything off. So I'm gonna give you the structure um approach towards the stations and what you need to do. And essentially um everything is gonna be the same once you follow um the tactics, the management that I'm gonna teach you tonight and I'm gonna speak a little bit about the combined stations as well because it seems a bit popular. So, is that what is the combined station? Essentially, it will be history taking um clinical examinations and equip management. Um, just a quick summary, a lot of pe um for those who has first attended the session, um I'm sorry, if it's just a bit repetitive, I'm gonna run through what you would be expecting during the exam itself. So during the exam, you go in there, 16 stations where you have one minute, 30 seconds in front of each room to read the prom. When I say read the prom is, you have to actually read them, run through every single questions in your mind, what the differential diagnosis are, what the management in. So that when you go in, you're more structured, you're more confident of what you're gonna ask, what investigations you're gonna take from them and what management you're gonna do it rather than just wondering about not knowing what to do during the one minute 30 seconds, I want you to actually read the prompt because I would say about 50% of the stations. It, they will tell you on the prompt. If it says take detailed history, address, the uh sorry, take detailed history management and uh address the concerns. So, you know, you have to do all these three things. But in some of the psychiatry stations, it will just tell you talk to the patients and address the concerns where you know that you actually have to perform well in your interpersonal skill or you actually have to listen to them to talk to them. So in the combined stations, this is tiny tip that I will tell you is just to take a peek into the room where they will have a little tiny windows at the side. So you can just take a room. If, if the room is slightly bigger with something close covered with cover, then you know, it can be a combined stations or if there is a Medica line on top of the table. So you would know and on the prom itself, it will tell you take history, take focused history or just take history, do the clinical examinations and tell the patients about what management you're gonna do and you would know there will be clue on, on on the prompt, telling you what to do. So in stations like this, I would do a quick run through of the most important questions I wouldn't be bothered about um everything like family history. Do you have any allergy if it's not relevant? Don't ask, just go in, tell me a little bit more. Start with open ended questions because the simulators, they are mostly very nice. So they memorize the script, they would tell you what they are experiencing what the complaints are. So it will save you a lot of time running through every single things like sores. They will if they tell you the first five, it started suddenly, when did it start? So you don't have to ask those clo close ended questions again. So just ask the reflex as well, any weight loss, any night sweats. And just the important question that you have to ask any past medical history, any regular medications. And that's it. If social history is not relevant, you don't have to ask in the combined stations. Time is essence where you actually have to ask targeted questions at the examinations that you need to do. Or if the patients say for example, they have got a breast pain, abdominal pain. So you have to ask targeted question based on around those symptoms. I hope it does make sense. And the reason that I'm talking about semen and this a three assessment as well. If you are unsure of what you want to do, you can always run through the A three assessment because in the pla two exams, what they want you to do is just how to be a safe doctor, how to be empathetic and how to practice basic medicine. You don't have to come up with some brilliant management because consultant can do that it's just af two level. So you just have to practice on the F two level, but you be a safe doctor, you're not killing the patients you refer or you talk to the seniors when necessary. So in most of the stations, what will make sense is you treat the symptoms, you order the necessary investigations and then you tell them I'm just gonna talk to my seniors to say if, to see if they have anything else to add. So that's pretty much it. That's your management cover. But how does interpersonal skill come in? It would be how you approach the stations in general. How confident you are, how you walk into the stations, you make eye contact with the patient, you smile to them every single even the most subtle details, they will score you in interpersonal skill. They don't want you to be like a robot. Um because if you go to an academy, they would just chuck loads of scripts at you at you ask you to memorize them and come up with investigations management if they're in pain, say sorry. So that's the reason why a lot of people will fail the first attempt in pla two. Hence, that's my personal experience as well because I would just go in, I would treat it like my actual patients where I would chat to them. I address the concerns when necessary. You don't actually have to say I'm sorry, just say, oh, bless you. That sounds really difficult. I can't imagine um putting myself in your shoes, you can just say something like this be empathetic, make the patients more comfortable. If the simulators are comfortable with you, they would help you. So they will give you more clue to the stations, more keys to the stations as well to help you with the diagnosis. So when you refer them appropriately, just treat uh I mean pain doctor, don't worry, I'll give you some painkillers and make sure the patients is clinically stable. Send off some basic, do some basic clinic examinations, take observations, listen to the chest infection p patients. They are not rocket science and just say I will order whatever scan that's necessary and I'll just do the blood test. I will refer you to the, if you are nauseous, I'll give you antiemetics and I will just speak to my seniors. That's pretty much it. So I'm gonna move on to the Sing Man stations now. So I'm gonna give you a quick overview of what the stations will be like because some of you are um have no, it it it will be your first examination. So you've got no clue of what you'll be expecting. So you will see when you go into the stations, you will see a semen a man line there with the examiner at the side. So you just tell the examiner straight, your na your name and your GMC number. Let's not waste any time and then he will tell you you can begin. So you go to the patients quickly. Just say hi. My name is, let's say for this, uh, for this case, I would just use Mister Andrew Smith. So, hi, my name is Dennis. I'm one of the junior doctors here. Can I just check your name and your age quickly? Um, so you can, if the patients is not answering you, you can always look at the wristband, but normally in the same man stations because they are quite fixated um, of a few stations where they normally come up where I will go through each of them later. So the patient said, oh, Andrew Smith, I'm 78 years old. I'm in pain doctor. So most people think, um where did the interpersonally, how do I go in if they tell you I'm in pain doctor just say, don't worry, Mister Smith, I'm here to help you. But let me just do a quick assessment to see what's going wrong. So you can carry on with the stations. Um Mister Smith, um, since you are talking, if the patient say I'm in pain or just grunting noise like oh help me help me. So, you know, you start with a, if you look at my slides, you start with a where you see if uh Mister Smith see here talking to me, I'm not worried about your airway or you can just say your airway will be patent. Let me just have a quick look at the monitor for you. Some people um some approach to the stations will be you take a history first and then you do your assessment. But sometimes I didn't do that. It's because I would strongly advise you to take history later because when you start to asking questions, you will, you will fall into the trend of taking a full history where you waste too much time rather than actually managing the patient. So I would look at the airway first because that would be the most important thing as well. If the patient's airways collapse, doesn't matter if you ask any questions, they're not gonna answer you. So just say if the patient's answering you airway is patent. However, if the patients is not answering you G CS is less than eight, you can say I will need to call the initative to come and intubate the patients. But in plaque scenarios in the plaque world, it's not gonna happen because they want you to do the full assessment. So in most of the stations, patient will answer you. So just say Mister Smith, since you're talking to me, your airways patent, let me just have a quick look at the monitor to see what's going wrong. So you move on to B once your b it will be your breathing. So you will be essentially looking at your respiration rate and your saturations, there will be on the screen for you. So in some scenarios, if you, you have to manage them as you go. So if the saturations is low, you can just ask the patients quickly. Um Do you have CO PD or are you smoking, sir? Are you a smoker? If not, you can target the saturations at a higher level where you can just tell the pa tell you can just say your oxygen level is a bit low. Mister Smith, I'm gonna give you oxygen where you actually have to go to the crash trolley on the crush trolley. There it will be A to e if you are not familiar with the crush trolley, I would advise you when you go to the academy look through the crush trolley because everything is there. So if you're going through breathing, so it will be in B where you have to put in 15 L via nonrebreather mask. You actually have to take the mask, pick the right mask, put it on the patients and then you have to adjust the oxygen. So if the and then you can move on to right? Um Mister Smith, can you tell me that? Then you move on to history taking here because you have already made sure the patient is stable. He's not gonna die. I immediately so you can take history. So for example, you can say Mister Smith, can you tell me what happened or um what brought you into the hospital? Then you take a quick history. I'm having shortness of breath or I'm not feeling well. So you can ask a quick one. If the patient is in pain, you can ask the sores, but just a quick one to help you with management. Not the full history. I will just run through a quick, um, do you have any other medical conditions or have you had recent operations? If not, you can look through on the table at the side of the table, sometimes there will be inhaler at the side. Sometimes there will be some medications in the anaphylaxis stations where there will be a back of blood transfusion running through. So you have some clue of what's actually happening in the postoperative bleeding, you will actually see see an operation s not where you can need to, you need to just have to take a quick look through what the patients have. And then you move on to let me do a quick examinations on you, Mister Smith. So you do your basic respiratory exam where you have to do the inspection, palpations, percussion. Most importantly, auscultation in B res auscultations would be the most essential part because in the semen, you can hear crackers, you can hear wheeze. So if any patients which is dealing with um respiratory problem, you would actually hear the findings. So with palpations, you can just do a quick one to do um and you can do percussion and then you have to do, the general inspection would be look at the patients to see if the patient has got any cyanosis. But that's it. So if you hear crackers, if the oxygen level is low, if you hear wheeze, you'll manage them. You just say I can hear some wheeze. Let me give you some salbutamol and you actually have to go to the trolley, get it and give it to the patients. And examiner will tell you when to stop if they want you to. And then after that, after clinic examinations, let's do systematic one. Move on from a clinic examinations, move on to investigations where you have to do ABG and chest X ray. That's the basic one. Just say Mister Smith, I will need to do a quick uh bloods from uh uh your blood gas from your vein, from your artery or from your little veins on your wrists. Or you can just say I would just book a quick um chest x- for you, then you move on to C. So once you're happy with B you realize you feel like the patient is stable, you have done whatever that you want to, then you move on to C because breathing is more important than circulation so that you don't kill the patients. So when you are moving those circulations, let me have a quick, you can just say the quick, just tell the patients what you're gonna do next because the examiner is listening as well, rather than verbalizing, looking at the examiner, they want you to tell the patients so that you can get your interpersonal skill, Mister Smith. Um Let me just have a quick look at the monitor again for your heart rate and your BP and that's it. So you look at the BP, you look at the monitor. Um you look at the BP and the heart rate. Sometimes the BP will be very low and heart rate will be very high. And in the sepsis case or in a a bleeding case where those are relevant where you need to do Cannula. But in all cases, I would say just save your time thinking if you wanna do Cannula, do them, but it's in an emergency scenarios. You do the biggest goals. You can say they will actually ask you what Cannula you wanna do. So you go to the trolley, take out either an orange or a gray cannula. If the patient is having severe hypotensive episode, it's better to put two of them. If there, if there are signs of bleeding, then you just need to put two of them, give them as much fluid as possible if not just do a quick fluid challenge. So after the canal is put in, just say, um I will take some bloods as well because just send off the routine bloods, your FBC, your U NE LFT, um your C RP and um group and safe if it is necessary. But in an emergency case, if you don't want to think, to think too much during exam, I would say you do everything because you're not gonna lose marks for doing more things than you needed. So just say I will send off some blood. So I, so I'm doing the cannula and just tell the, tell the patients I'm just gonna do a routine blood test and that's it. Um When you want to, if you want to do the fluid resuscitation, you have to take out the fluids. What you want to do in NHS. Normally we use uh sodium chloride as or a heart solutions as resuscitation fluid. But you don't, I would say pick your fluids, pick your favorite and stick with it so that you don't actually have to think or confuse yourself during the exam. So um your BP is a bit low. Mister Smith, I'm gonna give you lots of fluids via the cannula or in your veins. So just tell the pa the examiner would ask you if you don't say it, the examiner will ask you but just say I will give you 500 me over 15 minutes or you can um if patient has got history of heart failure, you just have to give it a bit slower. 2 50/2 50 mes over 15 minutes and then you move on to the next one where if you are happy with c and then you can move on. But if you're not in cases like acute limb ischemia where the patient is hemodynamically stable, you can always say I'll give you some maintenance fluid uh back over. Um for example, eight hourly or 12 hourly back depending on yourself what you like. But if patients is hemodynamically unstable, we start them with fluid straight away because once you have done those things, you can actually see on the screen that everything the patients a the the vital signs would actually be normalized or improving. And then if you are happy, we see um if so you've done the basic patient is stable, what you're gonna do, you're gonna do examinations, you're gonna do investigations and see what examinations will be most relevant would be. You just have to feel um the heart rate. You, you have to feel their pulse. You have to check for capillary few time and you have to auscultate, the heart sound, nothing extra, nothing complicated. And that's it. Look at the skin color, skin temperature just a quick few. So for any clinic examinations, not just for s even in the combined stations, you can al you have always, you have to start with inspection, outpatients, percussion auscultations if relevant. So if you have this in your brain fixated, memorized it and you any stations that come out if you, even if you are nervous, you know. All right, fine. I need to start with inspection first, then you know what to do and you move on to palpations, percussion and auscultation. So that's it in C oh, you have to touch the patient quickly. You have to, you can do a central capillary few time. We can check the pulse volume for this one. I'm not gonna ask you to do to memorize what we are ex exactly doing. So you can do, you can just follow your own pattern. What you're most comfortable with. Some people would be more comfortable feeding the pulse first and then check capillary, review time, check the skin temperature. But you can do especially with the skin temperature and your capillary review time, you can do it at the same time. So what you find out the examiner will tell you cap review time less than two seconds or pulse rate is normal. But if you are out, you can actually hear the heart sound because that's how great the semen's are. So if you're happy with C, you feel like OK, fine. I'm gonna move on to D. Now in D, I've got a Pneumonic where I normally use. It's called CPCR because there's so many things in D where you tend to forget, especially if you are nervous. So in D just have to go systematically with four things. C consciousness level, patients can be alert, responding to voice, responding to pain or unresponsive. So, so that's just C that's your consciousness level. P will be your pupil size where you actually have to take your torch and then shine it into the eye. You will be surprised to see the pupils are actually reactive and then you move on to our uh CPC that will be capillary glucose that you need to just to go quick BM. Just say um Mister Smith, I'm gonna do a quick um sugar uh blood glucose test on you. It's just a finger prick one and then r what R would be the most important one where it's called review where you have to go back to ABC again to make sure the patient is stable before you do anything else. Because in the same men stations, they will want you to stabilize the patients because this is what is expected of the junior doctors. So go back again, Mister Smith, let me just have a quick look at the monitor again or you can just say, how are you feeling now, Mister Smith? So I look at the monitor. So if you, if you manage the patients, well, you would actually see improvement. So in the breathing part, um the respiratory rate will come down. If you are, if you are giving patients oxygen, the saturations come out. So if you're quite happy with that fine and in the C se in the sea, if the blood, if the BP is coming out after your fluid resuscitation, then you can just stick to that. If it's not coming out, just say Mister Smith. Unfortunately, your BP is still a bit low. So I'm gonna give you a little bit more fluid. So you give another 500 meals over 15 minutes and then you move on. So if you are happy with D so that's fine. You move on to e exposure where you actually have to look the patient from toe to toe, from toe to from head to toe. Sorry. Um from exposure, I would say you just do a quick abdominal examinations, listen to the abdomen to see if there's any um bowel sound or you have to look at a private genital area. But in this plaque too well, or you can look at the legs as well, but in plaque too well, um what will be relevant to e would be if the patient has bleeding, you will see a pat on the back where you will see blood on it. So that would be the most relevant one, most important one you need to know in exposure, right? Fine. Now, you have got your ABCD E, if you are quite happy, if the patient is stable, you can ask, how are you feeling now, Mister Smith, I'm feeling better now, right? So you're gonna explain to the patients what they have. I think you might be, you would, you might be having this as asthma or you might be having septic shock. So you can talk about further findings or di uh further findings or further investigations you wanna do and then you can present to your seniors in some stations for semen, they will ask you to present to the seniors where the examiners will be your senior. So you need to do an sbar approach. But if they say if on the, in the prom, it says do the manage the patients and then talk to the seniors and then you need to know, you need to run through the ABCD E rather quickly give yourself about a minute or so to speak to the examiner. But when you're speaking to the examiner, like how you would refer the patients to any specialty where you do the SBAR approach, which is commonly used in the UK where it's situation, background, um, assessment and investigations, um, referrals. So you just say, um, I've got this patient who's a meet her with shortness of breath, I think she's got asthma and then you tell, just tell the examiner run through with them what you did so far. That's pretty much everything. So in terms of see men stations, there are a few bits, a few stations that I would say normally would come out during an exam because this is something, this is the scenarios where we normally encounter as a junior doctors anyway. So for example, asthma. So now from now on, I'm gonna give you a more re uh more specific investigations or more important management towards these specific stations. So asthma will be a good one where you have to give sabutal re re read through what dose you're gonna give 5 mg of sabutal via nebulizers. Uh Just know the important one. If it's not controlled, you can give IV hydrocortisone. So I'm not gonna go in details of every stages but run through these stage, run through these um scenarios and see what's the most important one. If the pa for asthmatic patients, if they are not, well, you can always give magnesium sulfate, but speak to your seniors first and then the second stage will be anaphylaxis where they will have blood transfusion or where the patients can breathe with more saturations. You need to give adrenaline, they will ask you how much adrenaline you're gonna give. So you need to know those things as well. And the third stations will be hypoglycemia. You need to give them glucose that you need to manage them at D. If you look, realize that the blood glucose level is 1.2. So you just need to give 10% um of glucose or 20% glucose, 100 MS. So it depends and the third stations will be the bleeding station where it's either postpartum hemorrhage, post or bleeding upper gi bleed. So that will be your bleeding stations where patient is extremely hypotensive where you have to give them loads of fluids in that stations. You will say I need to put in two Cannulas and I'll give you a liters. This a liters of fluid initially will be the max that you can give and will be recommended to give as well. And the next station will be the popular one which is sepsis. So if you can do the take three, give free protocol in sepsis, you're better than most of the candidates because this is what they want us to do as well. So take three will be blood culture. Um sorry, this will be blood culture, urine output and it's the other one. Um lactate, lactate. Yes. And then give three will be antibiotics. You'll give IV fluids and the other one. Yes, that will be it. So the next stage will be quite a stable one. That will be a more systematic approach like when you are taking your normal history. So there will be postoperative pain where you actually have to manage the patients. Um give them some morphine and that will be all. But you have to run through ABCD as well to tell the examiner what you were doing and how you're stabilizing the patients. And the next one, the last one, which is quite rarely that comes out during exam will be hospital, quiet pneumonia. That will be everything where you just have to give antibiotics and that's it. That's the semen station done for you. Any questions so far about semen? Well, I don't see any questions in the, in the chat room. We're gonna move on. So now we're gonna move on to the mock now. Um, I think Patricia here would like to be the fourth volunteer. Hello? Hi. Hello? Can you hear me? Yes, everything's ok. Um, so, hi. Hello. Can you hear me? Sorry? Yes. Can you hear me? I can hear you. I think I'm here. Hello. Mhm. Right. Hello? Can you hear us? Ok. No, no. Hello? Mhm. Hello? Oh, hello? Can you hear us now? I can hear you now. Sorry. Oh, I think it's working out. Is that ok? All right. That's fine. So our first station tonight, our, our stations tonight will be, our cases tonight will be on, um, a combined stations which is quite popular in exam. Now where, uh, recently I've heard you get two or three stations in every, in your exams. So, um, like I've mentioned for the combined stations, just remember a quick targeted history, get your red flex do clinical examinations. But unfortunately because it's virtual so we don't have the managing, but I will want you to run us through what you're gonna do, like inspection or spatial test that you're gonna do. Um, then I will give you the findings um, during the clinical examinations after examinations and then you tell us the management. So, are you ready? Yeah, like usual, I will give you one minute, 30 seconds for the, to read the prompt to go through everything. Um, I'll give you the advice that the GMC. Um, there was a, there was a person when you go for your lab too, um, who comes in and sort of introduces herself on behalf of the board. And she gave us this advice right before we went into the exam hall, she said, read the prompt and if you want to pass the station, read it again. Ok. So just focus on that. Yes. All right. Sorry, I didn't, I didn't hear the last bit. So if you want to pass the station, what you read the prompt and if you wanna pass it, you read it again. Oh, I see. Yes. Yeah. Ok. So I will, I will start the timer one minute, 30 seconds and good luck. Thank you again. Enter the room. Ok. Uh, I'm Patricia Guta Carrasco. My GMC number is 7699431. Hello? Hello? Hi. Hello. Um, I'm Patricia. I'm one of the senior doctors working in this department. May I confirm your full name and age, please? Yeah, I'm Selena Gomez. I'm 44 years old. Ok. Uh, how would you like me to call you? Selina is fine. Nice to meet you, Selina. Hi. Hi. How can I help you today? You know, doctor. I'm just really freaked out. Um, I was in the shower this morning, um, and I II was, it was just a normal day. I was just going about it and I just went for a quick shower and I felt like there was AAA bit of a lump um in my left breast. Um and I've always read that these things are quite um serious. Um And so I just thought I should see my doctor right away. Ok. Uh Yes, very welcome to, to come to us and uh we're gonna help you today. Uh We're gonna check on you. Uh So Selina before uh we move on, um I would like to know. So you noticed it today when you were having a shower? Um, could you tell me a little bit more about the lump or your back? Um, I mean, what would you like to know? Um, well, you said I was in the left, uh, is it one lump or maybe II can as far as I felt? Yeah, it's 11 lump, it's on the left side. Um, it's quite small. It's not too bad. Um, and II don't think it hurts me or anything because I didn't even notice it until this morning. But yeah, it's just there and it's really like, II don't know what it is. Can you tell me what it is? Uh, y uh yeah, we definitely can advise you. And, uh, but I would like to know a little bit more if that's ok for you. Yeah. Sure. Yeah. So I would like you to know as well if it's painful. Uh, no, no pain. As I said, I don't know, it was there until this morning. Ok. And, uh, well, you said you haven't noticed it before. Um, could you describe the lump for me? Do you feel it hard or? It's more like soft? Um, I would say it's a bit hard. Yeah. Um, and II, it's just that, I don't know. And it's small. It's not too big. It's not, yeah, it's not something I noticed until today. Um, have you noticed any redness on the area? Uh, no redness? No, uh, that you feel warm on your chest or? Sorry? Yeah. No, not really. No. Um, and, uh, have you noticing any, um, like f, well, like liquid or coming from, uh, your breast or any fluids? Um, no, not particularly. Ok. That's good. Um, uh, and what about the older breast? Have you noticed anything else on that one? Um, I did, I did kind of feel right away. Um, but I didn't think that there's anything in, in the right one. but I think a doctor should probably examine because I ii don't feel it but I'm not a doctor. Absolutely. And, yeah, if, if you're happy, yes. Uh I would like to have, uh, uh, if you're ok with that, I would like to examine you. But, um, uh, before that, uh, I just want to know, do you notice any changes in size of your breast? Um, no, not really. I would say that it's pretty much what it normally is. Ok. Ok. Um, and, uh, apart from this lump. Have you noticed anything else? Um, I honestly, I feel like I'm ok but, you know, my partner has been telling me that they feel like I've lost a little weight recently. Um, I, II think I've just been going to the gym often, so II really don't know. But he just tells me off and on that. He thinks my clothes look a little bigger on me and I just, my face, it, it just looks like I've lost some weight, but not quite sure. Ok. Ok. Um, and, um, mhm. Mm. How you feel? But your appetite is still the same, you're still eating the same things. Um, pretty much eating the same things. Yeah, I've just been, um, because I go to the gym often, I've just been watching my diet but overall, yeah, nothing's changed. That's ok. Um, and, uh, what about smoking? Sorry. Um, I do smoke off and on. Yeah. Yeah. Yeah. Ok. And, um, any, um, and what are you drinking? Any alcohol? Um, I drink socially with friends and family and things but it's not like II binge or anything, I think. Yeah. Just the usual. That's ok. Um, any medical conditions that you are aware of? Um, II have low thyroid. So I'm on tablets for that. Um, but other than that, I'm ok. Ok. Uh, and, uh, do you take your tablets regularly? Yeah, I'm quite regular with me. Sorry. Would you like to carry on with the examinations? Yes. Ok. Sorry. Uh, well, uh, Selena, if you're ok, I would like to examine you. Uh, the process will be, um, so, uh, you wouldn't need to be exposed from your waist to the top. Uh, and, uh, I will, uh, have a chaperone with me to protect your privacy and the examination itself will consist of me having a tender. Well, I need to palpate, uh, the breast area and I need to palpate the um the armpit area as well. Would that be ok for you? Yeah, doctor, whatever you need. I II really, I really want this checked as soon as possible. Yeah, that's ok. So what I would do is I would like my patient to uh expose that area. I will compare uh I will, I will inspect both of the breast to check for any asymmetry. Uh I will ask her to sit down on the bed and then uh move the arms at the back of the um the back of the neck. Uh Then I will ask her to put the hands uh sorry. And then I will, I will uh I said I will have a look and then I will ask her to put her arm on the was uh as well and then to lean forward a little bit just to change to see any changes as well. Then um after the inspection I will proceed with um uh with, with the gut. So I will go uh to, ok, just drink it. Sorry. So I think I will go for the left side. Ideally, I will go for the left side first and then I will move on to the right one. but for the exam purposes, I will try to get, uh, I will go that regularly for the left uh, breath, breath and I will start um in a circle away. Uh, and then, um, I will avoid to touch the nipple area. Uh and I will try to do like light touch and then to breath a little bit harder. I'm and then Oh yeah, sorry, it's ok. Do you want to just give your management plan? Yeah. Yeah. So um sorry, any findings from the findings first, the it's about three centimeters irregular in shape attached to the skin, we feel some tenderness and it's a bit warm as well. Ok. Um Well, so um that will be for me just a suspicious uh l lump. So we would need to do further uh assessments uh and that will involve uh um to have the patient um to go for. Mm. Well, we need to, she's 44. So I think it can be a mammogram. So she will need a mammogram. She will need ac so we can have a better uh idea of uh of the lump. Uh I forgot to say that I will also check the neck just in case. Uh there are all the lumps somewhere else. Um And then I will refer the patient with uh well, depending on the results, um I would check and refer the patient or consider the uh the patient to the. Um I think there is a breast clinic or breast cancer clinic uh for assessment. Uh she will need to have a full medical assessment uh with full medical history and full examination and she will also need to have some uh in is, well, more investigations we will include some blood tests. Um And then uh we mo sorry, maybe a bit disorganized. No, you're doing fine. Just continue. You're doing fine. Yes. Yes. And then uh ok, I will also uh discuss this case with my senior. Uh and I will recommend all this, uh this will be my recommendation. These are the things that we might do. So I will discuss this case with my senior to make sure that he is this person that my is happy. Uh And then I will um also check, uh it didn't check right now, but I could tell that the patient was a bit anxious about this. So also maybe some uh support, uh maybe uh refer her to the nurses, uh the nurse specialist, the nurse practitioner. So they can uh at um give some more information about this and they can be aware of all this and then I will um safe to net my patient uh and follow up. Definitely. So I need to see this patient again. Yeah. So you, I think you're pretty much you're doing too well, I would say because you've covered too much. Is this a short time? I know you've got eight minutes. So you need to be really careful with your history taking. That's the reason why I've always say if you go in, if you see the mannequin or if you see a blood, if you see a hand there where you need to take blood, you just have to be quick with your history taking. Just ask, I will go in, ask about the lump. Tell me a little bit about more about the lump. When did you notice it? And then you ask about the red flags where any weight loss, did you, did you notice any discharge? And then you move on any family history. I mean, you don't actually have to ask if you are smoking, but um just ask the relevant history because it will take about 4 to 5 minutes to do a good clinical examinations. So for the breast examinations, it's all right if you miss one of two things, but it's most important. Like I mentioned just now, inspection, palpation, percussion auscultation. In this case, you need to do a really good palpations and you have to check the lymph node, which you did. That is brilliant and you did the right management where you know, to refer the patients. Um So this in the UK, there's something called. If for any cancers, any suspicious of suspicion of cancer, you can refer them to the two weeks, wait pathway. Oh, yes. In two weeks. So, in cases like this, remember, you have got eight minutes and I appreciate 99% of the candidates who struggle with the management. That's why people struggle with combined stations because you will spend too much time taking history. It's fine if you miss one or two questions, but you just have to get the most important ones if it makes sense. All right, any questions, uh maybe just um, when do you know how to switch? Like when or how to do more nicely? Because I feel like I'm interrupting something and then I need to move on to the, to the Yeah, this is why your systematic approach comes in. You take the history, um the complaint and then the reflex means a differential family history, uh past medical history, medications history, family history is relevant, social history and then you move on. Um Right. So, um for this case, um Mr Smith or Selena, um Thank you for letting me, thank you for telling me all these. I'm just gonna do a quick examination to see what is actually going wrong. Then you explain the procedure which you did and you did offer chaperone and you asked for consent. I would always, in any cases, I would always say, um, if it makes sense or any questions so far just to check and check their understandings or if they have got any concerns if you've got the time. So in this, it's more time constraint in the combined stations where you just move on to clinic care examinations because that's where the wet of the mask is for that stations. Um I would just add something to that. Uh when you go into a combined station, right? And you're seeing this prompt in the front uh right before you went into the room, you, you see the last line, it's asking you to take a focused history, do relevant examination and discuss management. So when it, when you know that there are three things you're gonna be assessed on, you wanna touch those three things because you're gonna be marked all three things. So it doesn't matter if you've taken the best history but you don't finish or you rushed with your examination or you don't get to your management. So that's how you know where to stop and you know how much to rush because you might think you were doing this. You were doing that. But actually you did everything you, you took uh the right history, you gave a good examination and you had a good management but you didn't get to it. So don't try to dwell on one thing and try to make it perfect when you know the questions asked you three things just move on because it's not gonna look rushed. You're gonna feel rushed, but you're getting to the three things that were asked in the question. OK. OK. Thank you. Yes. Any other volunteers for the second se it, it would really help with your confidence and your flow during an exam. If you manage, if you are able to practice in front of an audience during an exam, it's just gonna be yourself simulating an examiner. You'll be like what to be scared about. I practice in front of so many people. So I think it's a good exposure. So any other volunteers, would you like to do it, Patricia? Sure. Yeah, we can go for it if you don't mind. Yeah, that's a good, yeah. All right. Thank you. Uh, second case the kittens enter the room. Uh, my name is Patrick Cosco. My na uh, DMC number is 7699431. hello. Hello. Hello. Uh, my, I'm Patricia. I'm one of the senior doctors working in this department. Uh, may I confirm your full name and age, please? Um, yeah. Doctor, I'm Daniel. Ok. Uh, is it? Ok if I call you Daniel? Yeah. Ok. Nice to meet you, Daniel. How can I help you today? So, I have severe pain, um, in my chest. Um, and it's been there for, uh, it's just started recently. It's been there for about two days. Um, and it just hurts, it started off as just like a pain that I ignored for a bit. But now it's just getting worse. Um, II, II don't know what to do. Ok. Uh, um, sorry, Daniel. Are you in pain right now? Oh, yeah, very much. Is it bearable? Uh, so I can continue because I need to ask you some questions. Is it wearable for you right now? So, um, yeah. Yeah, I think so. The nurse is just giving me a, a painkiller. I, I'm fine but II really need it to be checked. Um, yeah. Yeah, that's ok. So you are mentioning that you noticed it this two days ago and it's getting worse. Uh, could you tell me a little bit more about this pain? Um, yeah, like it started out of nowhere. Really? I wasn't doing anything. Um, it's more on my right side. Um, and two days ago I noticed it a little bit and II just felt like it, it, it was a muscle pull or something. It was not even that bad and now it's just, it's so painful and I don't know what to do and it's just been increasing. I have, I have not done anything to make it better or worse. Um, nothing I take at home has helped and II really am quite worried because this is not, it's not usual for me. Yeah. Yeah. Um, um, yeah, I understand that this might be a very frustrating situation, but we're here to help Danielle. So just bear with me one sec. Uh, a few minutes. Um, I just need to know some things, uh, apart from this pain. Do you have any other symptoms? Um, I mean, I've had, I feel like I've just been run down the last two days. Uh, I haven't really done much that I used to do. I, II don't know. I feel like maybe I have a fever. Uh, and I've just been really unwell but II live alone. I don't really have a lot of people taking care of me. I don't know. I, I've just been really unwell. Ok. And, uh, do you notice any changes in size in your test testes? Uh, I feel like there's a bit of swelling on the right side but not too much. Um, but it's more, it's more the pain and it's more like how it's affecting me overall. I just feel really unwell. Does the pain go somewhere else or it stays there? Uh, no, it's pretty much that. Ok. And, um, yeah, you mentioned that nothing makes it better that you were. Is there any, any, anything in particular that makes it worse? Any a position? No, no, nothing, nothing. Ok. And, uh, if you could score your pain from 1 to 10 being one, no pain or, uh, and then 10, the worst pain you ever felt? How would you score it? Maybe a six or a seven? I would say. Ok. Um, uh, so you mentioned that you might feel a bit warm apart from this. Have you noticed anything else? Um, no, II just had a little bit of redness and a little sweating down there but overall nothing much. Ok. Uh, ok. Uh, any discharge that you noticed from the area. Um, no, not exactly. No. Ok. Lumps and bumps. No, nothing. Ok. Um, all right. Ok. Uh, very well. So, um, so I would like to, if, if it's ok for you, Daniel, I would like to examine you. Yeah. Ok. Yeah. So, well, are you going to do anything invasive or just going to examine you? Uh No, no, sorry. It's not gonna be invasive. So, uh so what I'm gonna do is um so I need to examine the area for this reason. You're gonna be exposed uh from uh the waist below and uh I might need to have uh I need to palpate as well. The area I will have a chaperone with me uh to protect your privacy. Uh How does this sound to you? Yeah, that's ok. Yeah. And also that it, it painful, I will stop at any point you suggest. Please let me know and tell me if it's too painful, I will just stop. Yeah. Yeah. Ok. Um So what I would do is I will um well expose uh the patient. Uh I will inspect the area looking for any abnormalities. I will check uh on the size of the testicles or uh if there's any visible thing, uh then I will um move on to uh by patient. Uh And then I will start um but like this is is very sensitive area. Sorry. So I will start from the two minutes remaining. Yes, I will start from the inguinal part uh in inguinal area. Uh just to check for any lumps and bumps. Then I will uh check uh probably I would go for the left testicle first. I will try to touch it to find uh to identify the components of the testicles. Uh And to check for any inflammation, I will go for the right side as well, very gently and asking the patient if it's ok. Uh And I will try to identify as well, any pain or anything in there. So I think so. That's what I would do. Ok, I will. No, um no, sorry. Um no lumps that you can identify but when you lift the um the scrotum out, it's um the pain is relieved by eleva elevating um and testis. Mhm. Thank you. Uh ok. Well, uh Daniel, thank you uh for um let, let me examine you. Uh So from what we discussed and what we have done so far, uh it seemed to me that you might have um an infection in your testicles, uh something that is called epis, have you heard about this before? Uh No doctor. And I'm, I mean, I'm not that kind of a person. Is this like something I should be worried about? I II and, uh, have I got it from someone else or what? Oh, sorry, I apologize. I couldn't hear that. But, so II just said, is this something I should be worried about? What kind of infection? Yeah. And this is a very valid concern. Uh, but we might need to run further tests so we can identify the cause of your, uh, infection. Uh, I, if it's right for you to the next patient time's up. Yeah, it's challenging. It's not the, it's not the easiest case. Yeah. No, no. Yeah, thank you. So, how did you think about um how you did? Uh Well, I skipped a lot of things uh II wanted to do um like a more focused but at the same time, uh II think I was trying to follow the patient's lead what they were telling me. Um uh and then I think because the time I wanted to go to the examination and then when I got to the examination part, I was just skipped some steps. Uh So probably should have uh after the patient. Uh I think they, they do like a standing and then uh laying down in bed, I forgot to do the CMA uh reflex. Um So, yeah, I made some part, part in that. Uh and then in the management uh well, I didn't have the time to carry on. Yeah. So I think you did a good history taking. I have no problem with your history taking at all. But in this case specifically because it's um a suspicion of infection, it can be sti so you need to ask about sexual history. Um, but I would not ask the rest of the things I feel like in case in plan two exam where you are actually a, you're a doctor. So you don't II feel like you're too nice like you. Oh, you're constantly asking permission where it's time consuming. I know I will just tell them what I'm gonna do. I'm gonna examine your um test is now um Mister White and I'll get a chaperone here with me. Is that all right with you? Fine. That's all. I mean, they are there to seek your help and you're helping them. That's fine. I mean, I do appreciate that you want to get the interpersonal skill, but time is essence. So in case like this, I will just get the red flags. Any pain, any discharge. Do you notice any weight loss, notice any lumps and notice any infection, any fever? That's all. That's a differential done. I will. Yeah, I was just, I would, I would just add as you're saying that that if you're, you get a station with a symptom, like in this case, it's testicular pain. You would think of your differentials before you enter. In this case, you want to rule out torsion, you wanna rule out uh epidermal oritis or any kind of sti beyond that. I don't think you need to do anything for pla two. So if you're thinking of these three things, just focus your history on that, ask them those relevant questions for that. So if you miss sexual history in the station, it's, it's quite important. So you see, if you just keep those three things in your mind, you just ask everything related to that. You've asked it, move on, go to the examination. That's where you, that's the next thing. So just think about what you wanna rule out and focus your history just on those things. Don't ask anything beyond that. And for interpersonal ski, II did say that you have to be nice, but there are other things where you can add to your interpersonal ski as well. Like just even the simple things like, oh bless you. That sounds difficult. That sounds frustrating. I'm here to help you. So you don't have to keep asking interpersonal skill and be nice to patient. It's not about um take uh taking the lead because you are still in the consultations where you are taking the lead. So you would tell them what you would be expecting. You will constantly tell them what they will be expecting from you. But you can also say the few things like addressing um the pain, addressing the frustration, that will be all. So you don't have to, can I ask you a question? Like a lot of people go to the station and just say, um, uh, can I ask, uh, can I ask you a few questions on the pain? You don't have to carry on with. Sos just say first question I will ask, tell me a little bit more about it. And that's all they want to tell you carry on with the cross ended questions rather than asking them twice or three times. Any other symptoms, any other symptoms just carry on? Ok. All right. And also the, the patients that they're trained to give you a history towards your examination and towards the diagnosis. Right. They're, they've been already told what, what to say. They're not just there to answer exactly what you're saying. So if someone says they're in a lot of pain, it's getting worse. It's not, it's out of the blue for me. I don't know what's going on. They're trying to tell you that this is some kind of an acute situation and you can then use that and move on. You don't have to be very nice with your history. You can say, ok, I can see you're in a lot of pain. Let's see what's going on. Can I start examining you and you can use that to move on? They wouldn't do that if they've been told it's just a history station and it's something that they, you know, it's something, uh, that they need more reassurance with. They will lead you. So take the lead from the patient as well. But sometimes just a simple smiling at the patients who actually score you points because you've been a nice doctor as your, as your own personality. So that's who you are. Shall we move on to the third stations? Um Would you still like to be our volunteer Patricia? Uh Sure. Yeah, so the station is gonna be straightforward. I'll give you a hint. It's gonna be thin man because there's no, there's no hint on the station. Oh, just remember the A two E assessment, remember what I say just now? All right. Yeah, there we go. Ok, thank you. So I will be the examiner in this station where you just have to know what to do. Yeah, thank you. En uh my name is Patricia Rath. My E NC number is 7699431. Hello, hello. Hello doctor. Can you please help me? I'm very short of breath. Yeah. Hello. Hello. I'm Patricia. I'm one of the unit doctors uh working in this department and I'm here to help. Uh, just need to quickly check your name and age, please. Uh I'm James, I'm for ok. J uh James. Uh could you tell me how are you feeling? Why are you feeling? Uh I can't breathe. I'm, I'm really short of breath. Um I think my asthma is killing me. Ok? Uh please James bear with me. Uh um, we're here to help you now. Uh I would like to look at the monitor uh and check for patients uh sats and uh breathing rate, saturation is 78% on room, air respiration is 33. OK. 78%. Ok. Uh James. Uh So very quickly. Uh Do you have, uh do you smoke or have any CO PD? Um uh I don't have any COPD. Um I did smoke but I was told to stop uh because it was triggering my asthma a lot. So I haven't smoked in, in a few years now. Ok. Ok. So, um because you're having a very low oxygen level. So we're gonna put a oxygen mask on you and uh we'll put this um oxygen 15 L 100% and it's gonna be a hot flow uh through our reservoir mask. Yeah. So um uh as my patient uh sorry, uh James because you have been able to talk. So uh your uh airway, it seems to, for me it seems to me that it's patent. Uh So I'm gonna carry on with my assessment. Uh So we're gonna uh have a look on your um chest. It's a couple. Yes. So sorry. So I don't know if the patient is exposed. So I need to have a look on your chest uh looking for uh inspections to see if there's anything visible. And I would like to have a listen as well to the chest on auscultations. They are widespread wheeze across the chest. Ok. So patient complete sentence and patient is unable to complete sentence in one breath. Ok. Uh Very well. So I'm gonna give my patient uh salbutamol 5 mg uh nebulized. So I need to change my uh sorry. Yeah, I'm sorry. Uh we're gonna give you some medication to help you talk uh to help you breathe better. Uh So we're gonna change your mask uh for uh nebulizer uh mask and uh we're gonna give you some salbutamol uh 5 mg. Yup. And then uh I would like to check uh my patients. Uh Well, I would like to check the monitor. Um oxygen levels come up slightly to 82% on 15 L. Um rate is 25 at the moment. Ok. Yes. So I would like to continue. Uh So James, I'm gonna continue my assessment. I would like to request a chest X ray for my patient and I would like to do uh ABG oh. Yes. I um so I'm gonna uh move on. Um How are you feeling? How is it helping a little bit this Altol? I think so. II can't tell yet but yeah, a little bit, just a little bit. Ok. Um So uh we'll move on uh to my circulation assessment. Um Can I have my uh heart rate and BP, please? Uh BP is 120/80 heart rate is 125. Ok. So my patient is uh having some tachycardia. So I will like uh yeah, so I will uh so James I'm gonna have a listen. Uh ok, listen, I'm gonna uh feel your pulse uh and I'm gonna take some uh I'm gonna put um my finger on your chest to check your capillary refill uh time and yeah, and I would like to have a listen to your heart as well. Normal heart cell. Ok. Uh Can, can I check my patient's uh rest and oxygen level please? Oxygen level is coming out slightly 85% of 15 L respiration is still 23. Ok. How are you feeling your breathing now, James? Uh it's, it's better, it's a little better. Mm ok. Ok. Uh Very well. So um ok, so my patient seems to be improving. Um and then uh I would like to move on to t uh so James um but my uh as you are talking to me as well, uh your uh conscious level seems to be all right. You're alert. Uh I would like to check your pupils and um equal both people equal. Yeah. Just, just. Yes. Oh sorry, sorry. Uh I think that uh II would like to go back to see uh and I would like to put a cannula. I forgot. So I need to put uh 2 L4 Cannulas uh on my patient and uh just, just to, but we need to have a line and obtain some bloods. So uh we'll request uh FP CSE and left Uh I'm gonna check my patients. Um Oh, let's see. Oh, I forgot the name of the test. Uh Would you like to carry on? Yeah. Yeah. Yeah. Sorry. Yes, I will carry on. Uh And then uh I will check my patient's capilla lupus as well. Uh I I will, I will check the monitor. Mhm. Um Oxygen level is improving um saturation of 89% on 15 L. Respiration is 22% 22. OK. So my, so I need to keep uh reviewing him. Um How are you feeling now? Oh, sorry. Uh heart rate is 1 31 30. Um How are you feeling now? James um AAA bit better doctor but I feel a bit short of breath. OK. Um OK. Uh So um I'm gonna keep uh examine you. So mm what is the heart? Hi, sorry. I'm thinking so sorry. Uh Sorry. Yeah. Um OK. So I will reassess so I think I'm gonna go and check again. Uh The monitor was ok. Um So I will need to go to e um so I'm sorry I fell a bit stoking here. Um Because if you, if you stop, what what can you do? Yeah. So I will just reassess, take the monitor again. The patient was doing OK. Um And you don't have to save me all by yourself. Oh yes. So if you're stuck you can call someone for help. Yes. OK. Yeah. So I ii my senior. Yeah. So, in, in the first minute you knew that your patients having an asthma attack, right? Um, and you gave the nebs, that was the first thing you stabilized. You made sure everything was patent throughout. You try to stabilize the breathing as much as you could. If you don't know what else to do beyond that. For asthma, you can get a senior. Yeah, I think it got stuck because the heart rate was still high and it wasn't because I was breathless. Yeah. Yeah. Right. So um you did the basic, I would say you did the basic management. You kept the patients alive and you keep checking the monitor but it's wasting your time. I mean it's consuming your time but you did prove that you're a safe doctor but you need to finish the station. You started strong but you just kind of, I think it's just a nerve that caught you up. So you just kind of swear off slightly. Um So it's about your confidence. If you know that what you're gonna do, your confidence is gonna come in. This is why I've all keep mentioning ABCD E you go in Airways patent move on. I would normally reassess again after disability because you don't have time to keep going back and check unless the patient just suddenly crash, but it's not gonna happen in the exam. Well, so you should know if you are doing the right management if you know patients got asthma, you give the correct management patient to get better, as simple as that. So always go back to your ABCD even if you are stuck, you know. Oh, what should I do? I mean, it's only normal for people to get nervous during the exam. It's not just yourself. Most people struggle with semen. So you just as long as you're systematic, you know, ABCD E. Well, it doesn't matter what station comes up, you're gonna score. Well, like you're gonna excel in the station. So I would strongly advise everyone to go through ABCD E for yours, mens station. That's all you need to do. And then at the end for the refer for the presentation part or for the referral part I discussed with your seniors just have to read through them what you have done patients a meet her with shortness of breath about this 70 th how, I don't know how maybe 32 year old gentleman a meet her with shortness of breath. I think he's got asthma. He's initially presented with a breath Respi uh saturation of 95 8 85% room air. And I have given him oxygen, just run through ABCD E slowly with your examiner that will be good enough. So at the end, I would say, is there anything else? So I have done these tests. Is there anything else you would like me to? So that's all simple. Mhm Any questions from anyone? Do you have anything to add Amanda. Um, I just wrote some pointers about you when you were explaining your A to e in the beginning. Um, yeah, one of the things that you said is don't focus too much on history but, um, I would kind of say don't focus on it but do give your patient the 1st 30 seconds on the cement to tell you what's going on unless they're drowsy. Um, because they'll usually give you the answer, especially if it's a sep gestation or something like that. They'll say something's not right. I just don't know what's happening. If, if they're breathless, they'll usually tell you why they're breathless. Um If they say, you know, the, the, their chest feels heavy or something like that, you know, it's towards cardiac and it's chest pain, they will tell you what's happening or if they're just drowsy and they don't know what's going on. It's usually hypoglycemia. So I think just 30 seconds or 20 seconds give the patient to tell you, they might give you the answer and that'll help you guide your A two E as well. Um And just one other thing which is just very specific to what I went through with my, because I thought I was gonna fail that station the way I did it. Um, because I had hypoglycemia and my patient kept going in and out of conscious levels during my A two E. So I wasn't sure whether at one point, he was drowsy and I should manage his airway or one point he was giving me a history. So it was very haphazard. And one of the things I struggled with was to find the cannula because II said, I think the patient needs glucose. I couldn't find the stick for anything. Nor could I II said the next thing was 20% glucose. IV. And I couldn't find the cannula. I went through all the draws and this is just something that could happen to anybody is if you don't find those things that you're looking for, for example, you wanna change the mask. When you put nebs on, when you're physically on the exam, you might actually divert your attention towards finding this right equipment and it's ok to say, you know what to do, but you can't find it and assume you're doing it. So just say, um, I can't find it. I assume that this is, you know, I've changed the neb, so I've changed the cannula and that, and just keep moving forward. The idea is to finish your station and let the examiner know, you know what's going on and to be a safe doctor at the end of it. Mhm. Uh Everything will be in the stations if they want you to have the inhaler, if they want you to look at the operation chart, if they want you to look at the medications chart, it will be on the trolley. So when you go in, just have a brief look through everything. All right, you've done, you've done very well. I mean, um it's on, it's uh it's only humans nature to be nervous in practice like this, but it will get better. Just you just work on the time management and ask these specific questions, which is important. All right, I think it comes to the end of our session. Thank you very much. Thank you very much. Thank you. Thank you Patricia for um really being our volunteer for all three stations. Um I hope it was useful to you. Thank you so much. It was, thank you. Thank you. All right, it would be much appreciated and helpful if everyone could leave a feedback at the end of our sessions because it help with us planning the next sessions. What will be important? What would be relevant for you guys? All right, have a good evening and good luck in your exam. Who's for those who's doing the exam sooner and good night. Thank you. Thanks Dennis and Amanda. Um I've put the feedback form in the chat box and the event will uh was obviously recorded, so it will be in middle by tomorrow. Um So we can all watch it again if needs be. Thank you so much. Thank you. Bye. Thanks. Bye-bye.