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I'm hoping everyone can hear me. Um mhm If not, could somebody put in the chair if you can't hear me? But I'm gonna assume that everything is fine. It's always useful to assume that things are going. Ok? Oh, brilliant. Thank you very much. Um Brilliant. OK. So today we're gonna be using mentee again um in a slightly different way to how Megan used it last week, but I'm just gonna put the code in the chart here um just so that we can maintain a little bit of interaction um throughout and we can see what you're thinking about uh going through the station. Um uh This the first question should actually be on there if you do sign up to it and, and join that ment there. Um Which is this one here? This question, drum roll. What's your biggest concern about a pediatric station? Now, we've decided to cover pediatrics at this point. Um because I know a lot of people haven't actually done their pediatric block. Um 11 of you, no, like a third of you will have obviously, I was not one of the people who had covered it before um in fact, it was the one right before my ki which pros and cons, I suppose. But both the pediatric histories and the obstetric and gynecology histories are kind of specific. Um, and they have a slightly unusual way to approach the histories, which is why that we're doing the two stations, one on pediatrics this week and then OBS and Gynae next week before the winter break just to make sure that people who haven't had a chance to do the pediatric and the Obs and Gyne stations have actually been able to do it. Um So if you just wanna have a go at filling in and answering that first question, what's your biggest concern? Just so that we can make sure that we're targeting what you guys are finding the most difficult. The code is 35104981. Um And then we'll see, um we're just doing this whilst we're waiting for a few more people to sort of filter in. Um But yeah, if you could go on that ment there and answer that first question, biggest concern about a pediatric station, there's also the opportunity to use um Q and A on um on that ment there as well. Um So, um if at any point you want to ask any questions throughout, you can do it on the men, you can ask it in the chat. I can see the questions um in the chat, I can see the ones um on the meter. So wherever you want to ask questions, go for it, I will see it. It's just waiting for a few more people to filter in if people want to join that ment that's on the screen and we can have a look what people are thinking. It seems that a lot of people like the last time from the feedback and they said to continue using it. So we're gonna keep going um for another session. Um But it only really works if we get engagement with it. Um So we'll see, um it's also 90 quid a year and I'm not sure if we want to spend that at this point. Um ok, so biggest concern about pediatric stations, anyone you can answer in chat as well. No, we got that mean we're gonna leave it on for one more minute and then we'll have a look at the answers. Ok? Just place the mon code again in the chat there for everyone to join cos I can see that we've only got about four people on the mentee at the moment. And so if you've not joined it yet, jump on there. Ok. Um So we're five minutes past now. So I think we've left enough time for people to join if they haven't already. Um I'll leave the, the mentor code is on every slide. So please do jump in and join that throughout. Um Hopefully we can see that here. These are the responses we've got from that first question. Um So yeah, not having done a pediatric block. Um I think is definitely um an issue for a lot of people, like I said, a third of you um will have done it by your mock is, but the majority of you won't have. Um And even, even the fact that both the pediatrics and the OBS and Gynae um rotations are have those slightly different structured histories. A lot of people find that quite challenging, examining a child, you're very unlikely to have this. Uh the pediatric stations are the the II talk about it. Um But yeah, that would be very unlikely. Um during your pediatric book, they will teach you how to do a newborn examination. Um I learned it on a little, I actually have it here on a, a little one of these, it's a little duck. Um not brilliant, but it's not a super complicated examination of the newborn one. But honestly, you don't really need to do it in your pediatric book. You are likely to have. Um you are likely to have a um sorry, I got distracted, likely to have a pediatric is I had it in mine. It will be entirely dependent on if your specific hospital and rotation does it in that you will have to examine a child, but the child will always be a model. They won't get actors in to do that. Um When it comes to examining a child. The process besides the newborn examination process is the exact same. It's just that when you describe stuff to people, you're gonna be a little bit more um just gonna explain it in a way that they'll understand. Um So for example, in my pediatric is at the end of my block at a child who had to do a respiratory exam. So in my head, what am I thinking? I'm thinking, I wanna, I wanna have a look at the hands. I want to have a look at the face. I'm doing the eyes just doing a normal respiratory examination. And then I say next, I'm gonna have a listen to your chest and I say all that means is I'm gonna put it on your chest like this and I'm gonna do it to dad and the dad who introduced himself as the examiner. I said, I'm gonna do it to dad first, then I'll do it to you. Um And it's just sort of showing like, oh you can also do it to a teddy bear if they have something like that with them just showing like, oh it's not scary, don't worry, I'm doing it to dad the examiner at the time. Like I said, I'm just going to do it on dad first and I turned, it turned to him and he was like, and I was like, ok, um but I got really good marks for doing that part of it and it's just that be really like over the top about the fact that you're, you're trying to make sure that they feel comfortable in your actual whisky though. Very, very unlikely. I'm not sure what actors mean is your biggest concern about pediatric station. Um The majority of the stations that have been pediatrics over the past couple of years have been like, I don't really know the word to describe like 12 to like 15 year olds. Like they're not Children, Children. Um So and they, and, and they're acting, it is what they like to do um as part of like a club. Um Yeah, don't forget obviously they are kids. Um So you probably don't want to ask the super uncomfortable questions, but we'll go on to that it put on like I feel like ITP. Yeah, I was the ITP group. Um Yeah. Um but in the same way it's the sort of stuff that I talked about in, in the previous sessions as well when we're looking at any station they're not looking to see. Are you an amazing person who knows literally everything it's, are you safe? And if you don't know that it's ITP or you don't even know what ITP is or how to manage it, I didn't know how to manage ITP. And I said that I just said that honestly, I said, I don't know how to manage itp. So I would speak to my, speak to my senior about this and then I gave a guess and my guess was wrong. Um, but I was trying to show like what my thought process would be given the results that they'd shown me. So they, they showed me that the platelets were low. And so I said, I'm not sure, asked my senior if I were to hazard a guess, I would say that this patient may need a platelet transfusion if they got low platelets. But again, I'd like to check that with my senior and the answer was no platelets weren't low enough for a platelet transfusion. So the only thing I suggested was incorrect. Um But I passed that station, I passed that station pretty well. And again, it's not because like I knew how to manage it to be because I did not, but they are looking for a safe doctor and that's all you have to be is safe. Yeah, missing something important like sepsis or distress. I think this is something that we all worry about when you actually come across a patient or when you do stations and stuff, we make a really big deal out of sepsis in when we're teaching and everything like the, the actual symptoms, signs and symptoms of sepsis are actually really subtle. And when you have a septic patient in front of you, it's really easy to miss um and respiratory stress as well. I, when I was in G uh it's called PC placement my GP placement at the beginning of year five. So after I've done my ey and you, in theory, I would say the peak of my clinical understanding and the patient came in acute asthma. Um And I just didn't recognize the severity of the thing in front of me. This patient had reduced oxygen saturations. Uh This patient was on well, increased refrigerate, very wheezy all over. And despite the fact that if you asked me, what are the signs of severe or life threatening asthma? And I could rattle them off or on a pass question, I could answer it. The patient was in front of me presenting with those signs. I just didn't see it. So I called the doctor down. He was like, oh, this is a problem. I was like, oops. And so why am I trying to see you? I'm trying to say it's way more important that you don't get that wrong in real life. I got it wrong in real life, but we're, we're still at the beginning of our careers, right? There's always somebody double checking your work, right? Um In terms of the exam, if there is any doubt in your mind that a patient may have sepsis or a patient may have respiratory distress, I'm gonna, I would throw that word out there like when you're doing a medical interview and you throw like the words out there about like the four ethical pillars, that sort of stuff to make yourself sound great. You say that you love work life balance and you like going on walks, even though it's completely random and unrelated to the question, you're just putting those key words in there. So the examiner can basically tick that box in the head. Like yes, good team worker, good communication, good leadership. If I have any doubt that this patient may be sepsis. If they think that they've got an infection or if I don't know the diagnosis, I'm gonna go with sepsis because sepsis presents in a lot of different weird ways. OK. Um Right. We're gonna keep going with this. I'm gonna move this out of the way. Um We're gonna keep going with the rest of the presentation. The mentee is gonna stay the same um code throughout will be on the screen. So please do just join that and join him for the next couple of questions or put your answers in the chart. I can see that too. Um Right. OK. So let's go on with it. Um So yeah, overall this is where we are at the moment. I don't know. Um Yeah, here we go here where we are at the moment. We are doing pediatrics next week, we're doing OBS and Gynae. Um and then we'll have a break and, and then we'll do the data interpretation stuff before your exam. Um After that, ahead of your next one, we're going to look at the neuro, the psych and then some more data interpretation stuff specifically focusing on imaging. And then lastly, we'll wrap up with common and important presentations. Key thing to not at the moment we're going through these specialties because they have separate like slightly different histories that you need to take. Our purpose at the moment is not to teach you about these conditions. Um I imagine you already have notes from past me and stuff. Anyway, that last session with the common important ones, we are on the screen going to give you the summary of all of those common and important presentations for all of the ones that we think it's worth going through. That's not the stuff that we're doing at the moment. We're trying to teach you how to do the station because that's, that's the new, the different thing, right? Whereas you probably have a way to learn, but some people have asked for that sort of stuff so that we're gonna do that at the end sort of as a last minute revision, really pare it down to what exactly you need to know um, at the end for those common and important things. Um Yeah, so that's our timeline again. I just wanna make people aware of this CBD review service. Um You said that, um, in, in our, a couple of seconds ago, a little bit of uncertainty about whether your CBD was correct how to find a topic, anything like that, just email it to me, I will have a look at it and I'll give you feedback on it. We've had a few people do it already and it seems like people are already along the, the right tracks, do it early enough before your mockers so that we can look at it and send it back to you. Um But yeah, very happy to do that. If you have any questions about it again, we've got the Q and A open a message in the group in the chat as well, right? So session today, we will look at how to actually structure the history itself, important conditions that you need to know for pediatrics. And then we'll go through some example stations and we'll keep the um um the mental going as we go. So pediatric history then. So our first sort of question is gonna be what different things do we need to ask in a pediatric session? What sort of different things do we need to ask about? And then ment he's on the screen here. 35104981. You can also answer in the chat as well. What are your thoughts so far? What different things do we need to ask? Yeah, we do need to ask about vaccines, vaccines and the immunization schedule for is you do need to learn the immunization schedule. But it would be a good idea to have a rough awareness of what they should have had already for example, it would be a little bit silly to ask a five day old baby, what, what vaccines they have had because they won't, the majority of them will not have had any at that point because they're not scheduled any. Um, would you have a five year old baby? No, I'll talk about it a little bit but still worth it. Yeah. So, the birth history, the birth history, what happened during the labor? Um did the baby have to stay in the pediatric ICU for any point? Um and did anything go wrong if you are having a conversation with a parent? It is then also worth asking them like especially if they were the the mother of the person that carried the baby. How was it for you? And that's just sort of just screening for sort of like a prenatal depression thing, just checking that they're doing ok as well. I can see in the chat as well making sure that their milestones are met. Yeah. So you can ask that as some really general questions. Um or you can ask more specifically about height and weight, any issues in pregnancy. Yep. Um birth history, nutrition. Yeah, this is also important as you get older. So in a child like in a uh in an infant, I mean, um you want to ask like, are they, are they breastfeeding? Are they bottle feeding? Are they moving on to any solids yet? And when they're older, you may want to ask a child what their attitudes towards food are just for screening for eating disorders. Ok. Sleep habits. Yeah. Growth and development. Lots of people love and growth and development. Um, yeah, you can ask about social service involvement. Um, smokers in the house. Yep, definitely. Um, and yes, safeguarding is a really important thing. We'll talk about how to do safeguarding and who's at home. Yeah. So you can ask who have got home with you. And then if, if they, if they don't really know how to answer that question, you can list, you can list family members that you may expect. Um, any conditions that run in the family, who cares for the child most of the time? And how are they getting on at school? Yeah, school is a big one. Are they going to school? How are they getting on? What are they like? Um, yeah, e enjoyment is a, is a big thing as well. Um, and focus. Yeah, I can see that as well. Yeah, congenital issues like dysplasia and parents. Yeah, that's a good idea. Um, when you're talking about family history, um asking about specific stuff and especially congenital stuff is more relevant the younger you are as well. So it's extremely relevant in pediatrics. So, yeah. Brilliant. Ok. Scoot that out of the way. Um So, so certainly I agree with all these things when it comes to the actual pediatrics station in itself, where does it fit in where it's most likely gonna fit in in one of these three stations in the Acute station, the SBAR station or the communication skills session. Now, we've talked through AQ and SBAR already and the communication one is just the history station, right? Um So the only difference between the top two really is just whether you're doing a skill or sbar, the bottom one is just that you've got seven minutes to take the history from previous years. The majority of pediatrics sit in this communication where they have a seven minute history. And again, the majority of the ones in previous years have been a a child by themselves, age like teen, teenage years. And I'm saying that specifically because we need to learn those skills of how to take a history from a loan child has to take a history from a lone child. So, um so in terms of general advice, repeat station, it is very similar to other histories, but we've got those few extra steps, which is what you guys have been picking out already. Um So like I said, the majority are going to be Children by themselves. So you need to figure out, well, where are your parents or where are your guardians and make sure that you've actually consented the patient. So, like I said, I had that ITP case, I had about a 14 year old girl who came in the examiner told me their parents are parking the car and have said it's ok for you to speak to her whilst they're parking. And I'm great, brilliant. Thanks for the examiner for telling me that, but I still need to consent the patient. So when I introduced myself, I said hi, I said, I, one of the medical students, um, what, what's your name? Do you know when your birthday is? And I said, so I've been asked to have a chat with you today, but I can see that your parents aren't here right now. Are they still out parking the car? And she's like, yes, and I'm like, brilliant. So, do you want us to wait until they come in or do you want to just have a chat by ourselves? That way, I've given the option now in an I, they will just say we can just have a chat. That's fine. Um But you just wanna make sure that you've really explicitly made that. And then I said, if at any point you want to stop and wait for your parents, then, uh, then we can do that, just let me know. Ok. And all that's done is just really made sure that this patient is ok with the situation. Um Just in the chat. Yes, the this is recorded, you get access to it if you fill in the feedback at the end. Yeah, and safeguard. So that's part of what we've just said that safeguarding is for both yourself and also for them. Right? Is that you're making sure that they're not there. They've not been abandoned there. Number one, like they know where parents are or where the guardians are. Um, and they also, you're not, you've not taken this history from an unconsented patient when you speak to, um, these patients as well. You want to make sure that you are asking if they feel safe, that they feel comfortable and that comes into the social history. And we'll look at some examples of those ask questions to make them feel comfortable. Now, what I mean by this is you may want to ask some more, not clinically relevant questions that may just make them feel a little bit more comfortable. For example, a few people said about school and then we should ask about schooling history. We certainly should. Um and we should ask, are you at school at the moment? How are you getting on? Um What I then like to ask is what, what subject is your favorite subject? And you can have a little bit of a chat about that. Um I mean, I think I'm not sure if my example is the best. Um I spoke to my patient and I said, um, oh, what's your favorite subject at school? And she said maths and I said, maths should I put that down as a symptom? And it made her laugh, it made me laugh, but it was just a, a nice little moment. Of like we're both two people having this conversation and she seemed really comfortable after that just because we had this little joke together. Right? Did it get me any clinical information? No, but it's rapport building, especially because she was quite nervous and she was about like the conversation we were having. And so was I realizing it was itp um explain and ask your questions simply. So what I mean by this um is that these uh we already have to talk about things in patient terms, right? We can't talk about things in complicated words, but you're, you're talking to a child. Um And even if you're talking to a parent about a child, they don't want to have any amount of uncertainty and they will call you out on it if you start saying something that's more complicated. So instead, instead of a lot of people will say, do you have any family history? Um And for me personally, II wouldn't even ask that to patients that are adults because I still think that family histories are still a relatively scientific term. But just like, does anyone in your family have anything like this? What about? And then if you've asked about your who they live with, you can ask like, oh, does mom have anything like this? Does dad have anything like this or whatever their family structure is? You could just ask specifically about who they've brought up already. If at any point you're having to explain anything again, you want to use these really simple, easy to understand words about why you do or don't think that something is what you're describing. OK, as you guys are all brought up developmental history. Um And I'll go through some examples later, but like I said, the majority of these will be Children by themselves. It is hard to get both a developmental and a birth history um because they simply won't know it. Right. Um, so you can ask, and if you don't know, say, don't worry, I can ask your parents when they get here. So, just adapt to the situation. Whereas if you have the parents, you can say, ah, are, are they meeting all the, are they meeting the, are they developing normally? Are they meeting their height centiles? Do you have the red book with you? The red book, if you've not done pediatrics is a book that you have for Children. You're supposed to keep it for longer. I, most people after the age of about three just seem to lose it, but it's supposed to have all the developmental stuff. It has those height and weight sent charts on it, um, or records of vaccines and previous uh interactions with health visitors and nurses. Right. I've said here about the birth history and I've said here specifically, if less than five years old, the majority of the time, if you've got a 15 year old patient in front of you, their birth history is not relevant. Um, but if I've got a patient who's presenting with like a limp, then I do want to know if they had any complications during birth that may have led to developmental dysplasia. So, for me, generally, I would say if they're less than five, that's when I'd be asking about the birth vaccination status. Again, person themselves may not know, um, a lot of people, um, We find out assume that they were vaccinated as a child at work. Um So you can ask the child themselves and then if they don't say no again, just don't worry, we can ask your parents when they get here or I can check the records. That's fine. We'll move on. They may remember getting their most recent one. So if you're thinking about like a 14 year old, they may have had their HPV vaccine and lastly check they're leaving to a safe place. Now, what I mean by that is when you wrap up the consultation, you don't want to just be like, all right, bye. Like, remember this was a child, this was a child alone who presented to you. So the way that I wrapped up my consultation and I would recommend that you consider having a script like this. I've got it written up somewhere later. Um But um ok, so I've asked you all of the questions I need to for. Now, I know your parents are still out parking the car. Do you want me to stay and wait with you until they arrive? And then like, I've not given them, I'm like, do you want that? And then they can say like they will say no because obviously you need to go to the rest of the station. But I've considered, look, you're a kid. Your parents are, I don't even know where I'm not gonna leave you alone. So I'm gonna wait with you and then they will say no, but there we go. So these are key tips that I would be trying to think. Just make sure that you're used to asking these things, explaining things in a simple way and just being what I would describe as probably a bit over the top in terms of safeguarding like, you know that these kids are ok because they're, they're actors, they're here with their acting crew, like they're used to being left alone because that's what they do in between all of the stations. They'll just leave this, the students themselves don't stay around whilst you're doing the rest of the station because I don't know if people realize, but medicine is kind of scary. So you don't really want to stay around for the management part of it. So they will leave and it's just quite difficult because you have to get over the fact that like at the end of the day, this situation is ridiculous of just like everyone sitting there, like you're pretending to be a doctor, they're pretending to be a patient. There's a person in the corner using an ipad just to, like mark boxes. Like, it's just a really unusual situation. But if you've got those things in there, like, if I'm presented with a kid, I'm making sure that if they're without a parent that I'm checking that they're ok and that they've got somewhere to go afterwards because would you leave a 12 year old to just wander away? Yeah, that's just probably not, you probably like a child, take care of you somehow, right? Try and apply that. It is hard because it is an artificial scenario. Ok. Again, if you want to put any questions in the chat or in the Q and A um on ment to please do, can I just check the Q and A? Yeah. No, no one's put anything in there. Yeah, that's fine. Um ok. All right. So we'll keep going. All right. So in terms of the pediatric histories, what I've done here is that I've just tried to give you the introduction of the stuff that's slightly different to a normal history. If it's not different to a normal history, I've not included it and I've given you an example script for each. What do I mean? I mean, for example, with like past medical history, I've don't think I've um I may have included actually family history, not really included that because the only thing that I would change about family history is asking it in a simpler way. I wouldn't say, do you have any family history of cardiovascular injuries? Like, no, I wouldn't like, I'd ask that differently, but I'm not gonna give you a script for that because you'll just say it however you want. So intro, obviously, name role, greet your child, confirm their identity, ask where their parents are if they'd like to wait for them first and explain what is going to happen. This is the most likely situation that you'll have. It will be a history and it will be a kid by themselves. If it is a collateral history, then obviously you introduce yourself to the parents and just make sure you confirm the identity of the child that you're talking about in the same way that you would for any other collateral history to, to just flag up collateral histories are fairly common. In this case, at least one of your stations will probably be a collateral history. Just make sure that you're aware that that's, that could be a thing the majority of the time it's the same um as a normal history. Um Just making sure that if they don't know the answer to a question, don't make them feel bad for it because they're not the person. Um For example, hi, my name is De, I'm 1/5 year medical student. What's your name? When were you born today? I've been asked to have a bit of a chat with you about what's been going on. But I know your parents aren't here. Where are they? Are you ok to have a chat by yourself or would you like to wait? It's just given that nice little intro, it's not added that much more to the normal chit chat at the beginning of a history, but it just make sure that they're feeling safe and you've safeguarded them, excuse me, leaving a break because I know I speak a little bit fast. Um, yeah, so you can see that I've identified those key points and then I've asked those again in simple ways. I'm not saying what's your date of birth like I would do for other histories. I'm asking, when were you born? Ok. For the next part of it. Then past medical history, we're gonna ask generally about surgery and then we're gonna ask about the developmental birth history and then I've put in brackets or have a backup plan and that's what I was talking about earlier. So, do you have any other conditions? Do you see your doctor for anything regularly for had surgery? And you can ask a parent any concerns during the birth, any concerns during the labor, any concerns about the development or to a child? I'd like to ask a little bit about, ask a bit about when you were born, but your parents aren't here. So I'll ask that when they get here. Does anyone know just in, in the chat? Why have I said? But you, why have I brought it up if the patient can't answer it? Cos I know that I'm not gonna get any information from a 15 year old about whether there were issues when they were born. Why am I saying it? Yes. Exactly. Sometimes we're signposting things for the examiner rather than for actually us gaining information in the same way that at the beginning of um uh as you talk through an examination, what I would often do is talk through some relevant negatives or positives that I'm looking for. So I would say I'm looking around the bed for any ad airway adjunct to see if they've brought anything in with them, like a cane or any medication. I've just listed a few things. If I've not seen anything, I've just told them this is what I would look like for if it was here. So, yeah, I flagged it up to say to the examiner, look, I know um for example, I can give you an example from my about when I did something like this. Perhaps not in the best way where II think I told you about the acute station and I had the acute station of a patient with mania. And it is very difficult to take a four minute history from a patient with mania because they talk a lot and they're enjoying talking a lot and you will enjoy talking to them as well. Um But I didn't manage to do the red flags, which I know everyone's like, that's a no, no psychiatric red flags. I didn't get to ask about risk to self to others suicide. Ok. Didn't ask about these questions. Um So when I presented to the examiner, I didn't, I didn't fail the psychiatric station because, and that would be a huge red flag safety concern. But when I presented it, I turned around and I went through all the history that I went through. And then I said to complete my history, I would like to ask about if they've had any thoughts of harming themselves, any thoughts of suicide or any thoughts of harming anybody else. Um, to, to, to carry out a psychiatric risk assessment to summarize this is what I missed. So if you do miss something in any history, a cue or not or in an examination, I did that in my neuro one where I just didn't test tone. You don't need to test to, uh where at the end I summarized my examination findings and I said to complete my examination, I'd like to do an assessment of the patient's tone in all four limbs, right? If you forget something, it's fine. Put it in your conclusion, you won't get as many markers as you would have got. If you'd done it, this, that's for sure because that's poor time management. And I accept that poor time management. I waffle as you can tell, but it's just important to know that like if you do realize that you've messed something up, you can go back and be like, 00 yeah. Um I'll give you one more example before I move on again in my actual whisky chest X ray. I look at it. I'm like, that's pretty normal to me. So I do the thing where I talk through ABCD again, we'll talk through data interpretation next month. So if you've not, don't know what I'm on about, then we'll do it then. But I talked it through this a, this is a normal chest X ray. Um And I said, well, given in this, my differentials are blah, blah, blah. And they said, given the inf given the di likely diagnosis of an infective exacerbation of CO PD. And I was like, oh and so II glanced at the X ray and I was like, oh, yeah, this X ray is not a normal chest X ray. This is, this is a chest X ray of CO PD. And so what I said to the examiner, I was like, oh C OC O PD that explains the hyper expanded lung fields. And I was like, OK, so look, I didn't do it at the time. You've told me that in retrospect. Yeah, I can, I can see what I didn't see the first time around. So I said that and I answered the question about management again. Did I get as many marks as I would have if I'd done the investigation interpretation correctly the first time? Definitely not. But II did pretty good in my, I, but the majority of stuff I can say about my I stations is the stuff that I messed up and that's fine. Like the majority of people come out and I think it was rubbish. Yeah, it feels like that. But again, just be safe like you're not supposed to be perfect. Um I just don't want you to lose faith in, in me for teaching you this and then I tell you all the stuff that I did wrong. Um So yeah, if you've noticed something that you've done wrong, go back, just let him know and point out stuff that you would ask about if you had it. Ok, sorry, I'll keep going. So drug history ask generally allergies, immunizations as you guys said. And again, if you don't know, have a backup plan, do you take any medications? Do you have any allergies? You can ask that in different ways. Have you ever taken anything? And it made you all puffy or difficult to breathe? Um Have you heard of all your vaccines? I'll ask your parents when they get here about vaccines as a baby. So for social history, um a lot of people use the acronym head. Some other people will use the acronym head, which I've just put in the chat with extra ES and SS. And I'll be honest, I don't think the majority of these are appropriate to ask a child. In fact, we got told off during our pediatric, um, uh, block for trying to include everything that is in the head's acronym. So head as itself is home life education activities. Like what do they like to do? Um, and drugs, drugs, meaning, uh, alcohol, cigarettes, that sort of stuff. Um, the, the other ones for s, for example, is supposed to be sex and relationships. Um, but you really have to tailor this to the patient that you have in front of you. I didn't think it was appropriate to ask the child in front of me about illicit drug use or sex and relationships because I didn't think it was relevant to what was in front of me and I didn't think it was appropriate to ask a child, especially without somebody else present. Um, and that's sort of the vibe that both pediatricians and also GPS tend to take when they have a child. Uh, I don't know if many of you have been on GP placements where you've had a kid. Um, uh, I've had a few Children come in who have something like query Thrush, um, or even something like Nappy rash. And for me, in, in my head, I'm like, ok, well, to make a diagnosis of that, I need to see what it is. Right. But when you've got like a five year old that I've never seen a GP in do any sort of examination that isn't respiratory or feeling tummy on a child. Um, and so this is just a bit of a difficult one in practice. We would, we don't do that. Um, unless it is absolutely necessary if I've, if you've got a child who's come in with recurrent thrush, um, then yeah, maybe you might wanna have a look to just sure there's no anatomical abnormalities that are causing this. But in actual practice, you don't tend to ask Children or even teenagers about the majority of these things. Unless they are specifically relevant. If you are in gynecology and you have a 13 year old, you're probably going to ask about sex and relationships. But if you have somebody come in with a query, asthma attack, you're probably not. Ok, ask questions that will help define your diagnosis. So what do I mean by these different things home who lives at home with you? Do you feel safe at home? You can all, like a lot of people suggest that you can go into a bit more detail. Like, do you have your own bedroom? That sort of stuff for an, I don't think it's relevant, I think. Who lives at home? Do you feel safe? This is safeguarding um education. Are you in school? How are you getting on? What's your favorite subject? What's your favorite subject? Like I said, that's a personal rapport building question. It's nothing to do with your diagnosis. Whereas contrast that to a question about sex and relationships, it's definitely not report building and it's not gonna add to my diagnosis. So I'm not gonna ask it. Um, if you are going to ask about drugs, cigarettes or alcohol, the way that I would phrase it would be like many people start using drugs or cigarettes around your age. Have you tried any? Um, but again, I did not ask this in my history. I did not think it was relevant. Um, uh, you could always, like I said, add stuff afterwards so you could present it to the examiner once the, um, the child has left, you could say if I thought it was relevant, I would have asked about drugs, cigarettes and alcohol use, but I didn't think it was important at the time or I didn't think it was relevant to my diagnosis. That's just my recommendation for it. Uh, oh, sorry about that. Ignore a bit where it says closing and they just repeated that previously, but to close. Um, we'll just look at the example to close your history. You just wanna make sure that you have that nice summary that I was talking about. Well, thank you so much for having me chat with me today. I'll speak with my supervisor and see how you can help you going forward. Your parents still aren't here yet. Would you like me to wait for you with you until they arrive as with all histories. I still do think it's important to ask the person if they have any questions for you just be worried that if you ask that may, they may ask you something? Um So don't ask about it if you're super not confident. I think I told you the last time I did uh one of my examinations was a thyroid examination and I asked them at the end, I was like, thank you for letting me examine you. Do you have any questions for me? And she said, yes, why did you look at my hands? So I had to then explain what I was looking for in the hands. Then I'm explaining to them and I'm also explained to the examiner that I'm not just going through the motions. OK? So that's in terms of giving you a little bit of a script and those specific things that we wanna go through. Now, in terms of conditions that we actually want to consider, let me push this forwards one on the mentee or in the chat there, you tell me what pediatric conditions do you think might come up in your ey. So remember common and important conditions is what we look, what we're looking for for an e what do we think pediatric conditions on here or on the chart? Again, ment codes on the screen, but I've also put it in the chart as well. For you. People love bronchiolitis. Yeah. Asthma and bronchiolitis. Yeah, I agree. Asthma, exacerbation. Yeah. Meningococcal septicemia. Yep. Important thing to bear in mind when you're looking at meningococcal septicemia. Just, just like, so, Megan, the, the doctor who did it last week in her year, she had a child, one on one history. Just the same as with my year. Rash. Very similar to my year as well. Um, yeah. And, uh, neck stiffness headache. So she says uh this is meningitis um and talks through the meningitis management. But of course, when you've got the rash, that means you've got either the meningococcal septicemia or you've got D IC of some kind, right? Just be super clear that if you're suspecting meningitis and meningococcal septicemia is what you think sepsis is, is what you're dealing with, right? So she got red flagged for it because she said meningitis, but she didn't say sepsis. And so again, this is just me trying to flag up the sepsis, but it is hard to get like she did. Well, she's a good doctor but she didn't flag up sepsis in a patient that has something called meningococcal septicemia, right? Um So yeah, do just bear that in mind. Cystic fibrosis. Yeah, acute asthma attack, rash, rash is very common. Um But I wouldn't get too bogged down with all of those infectious viral rashes that they will talk to you about on past med with the rashes for this are gonna be the important rashes. Um, you need to be able to tell the difference between something that I'm concerned about sepsis and something that I'm not, um, croup. Yep, eczema or acne. Yes. It certainly, so dermatology could come up. Um, again, remember that these are histories. It is hard to get a dermatology, um, diagnosis from a history. Um, I'm sure that you get that from if you do a pass med question and it doesn't have a picture in your life or sometimes if you do a progress test question and it has a picture of it and you're still like, mm so yeah, dermatology ones can come up but if they're gonna come up, they're gonna be really easy to diagnose from the description they are giving you or from the results that they might do. Um Yeah, diabetes type one is the one that you're most likely to come across in a pediatric station. Yeah. D DH II think it would be very unlikely to actually get a baby. Um, you wouldn't full stop. There's no, no babies will be coming to the exam, right? I, but I think it would be unlikely to get collateral history from a patient for a baby. And that sort of applies to the Down Syndrome thing as well of just like congenital things. It will never be that you have to diagnose something like that from a history because much like a because a Down Syndrome and has a a syndromic appearance and you don't the, how would you describe that through a history? Does that make sense? Um Yeah. So it, it may be more a lot of complications, but I think I would learn these sorts of things for a written progress test exam. I don't think these are likely to come up as an issue. Um And I didn't revise either of them. I also didn't revise IDP but separate, separate story. Um Adhd, anxiety, depression. Yeah. So generally mental health very common uh station for um for teenagers specifically. Um I think you'd be unlikely to get something. Um uh I think, yeah, I think it, you'd be unlikely to get like ad HD in like a six year old, for example, eating disorders. Yeah. In, I think equally very likely to come up. And I think they're, they're slightly harder, but we have a station on psychiatry where we will talk about specifically when you're doing an eating disorder, depression. Um your developmental disorder or um uh psychosis history because you s you phrase them slightly different, you have specific questions that you want to hit. Um So with eating disorder, oh, alcohol use as well is another one that we'll talk about. I think it would be quite nasty to give you an alcohol use question. Um But we'll talk about how to do it just in case it does come up because it is useful to know uh the important things to ask. Um Yeah, brilliant. So it seems like you're already on the right track. But remember when it comes to actually doing the stuff is common and important, think how, how likely am I to come across this? I've come across asthma countless times. Um In just even me, my GP block, let alone my hospital block. Um I've come across cystic fibrosis and that's a rare condition. I've come across about four times already and I've never been on a respiratory ward. Comes up a lot. Um, but in, in the context of a hospital setting or a GP setting, I've never come across a patient with Down Syndrome in my personal life and beyond, I've come across lots of patients with Down Syndrome, but it's just not something that I've come across in, in hospital. Um, yeah, so conditions to consider. Um, these are the ones that I think it is worth going through again. Not an exhausted list. I've not put Down Syndrome on here. For example, that does not mean that Down Syndrome won't come up. It's just for me when I was going through it. Um I thought how would I write an ey station about developmental dysplasia of the hip and I struggled to do it. Um And if that's the sort of thing that I come up with, I'm like, I doubt that that would come up. So asthma, bronchiolitis, croup, whooping cough, cystic fibrosis, celiac disease, gord type one diabetes, meningitis, seizures eczema and otitis media because these are all easily described in a history. So, even whooping cough, for example, it's a bit of a stinky history to take, but they will all have that inspiratory hope. Right? Um, so when you talk about it you'll, you'll understand what you're coming across. Um, ok. Um, so I'm gonna press a button here. Um, I've put a thing up here. You can put it in the chart as well. Why have I highlighted these ones? Vi asthma type one, diabetes, meningitis and seizures. What's different about those? Yeah, I'll put that on the screen because not emergency dangerous boys. Yeah. These are your acute emergency ones. Yeah, exactly. And check, these are the ones that become a medical emergencies. So I put these on here because like I said, I think that these are likely to come up as either the sbar or the acute station. It can come up as a communication skills one, but there are more acute stations than there are com skills ones. And therefore I wanna make sure that I know my emergencies. Yeah. Um, so you go, I've put what the emergency is. So what's the difference between asthma and acute asthma then? Well, it might be a stable asthma patient but it's got increasing breathlessness. Type one. Diabetes could be a patient that has it already or he's just got increasing tiredness without coming in being acutely unwell. Um, yeah, seizures when it comes to doing seizures for pass med. And uh uh no, you, you'll come across this, you come across it already or you'll come across it soon where stuff is really clear cut when it's in past me where it's really easy to tell the difference between a febrile convulsion and epileptic seizure. It's just not like that in real life. So I've just put seizures here. I've not put epilepsy, I've not put female convulsions. And so in a history, what I, what would I say on my differential diagnosis? I'd say my differential diagnosis for this is a seizure. This could be secondary to epilepsy or a febrile convulsion, but you can't tell any of that from a history and that's just really important to, to get your head around. There are some things that point you in different directions like if you have a vasovagal syncope, um your low BP can result in what appears to be a tonic clonic seizure. It's not the difference between a seizure and vasovagal syncope that's resulted in this seizure. Like appearance is epilepsy. Patients often will feel very unwell afterwards for up to uh over an hour. Vasovagal patients will get better within 10 minutes. But if I have a patient with known epilepsy who's come in with a tonic chronic looking thing, I'm not gonna say, oh, well, it's not, it's not epilepsy because you recovered, right. So just just bear that in mind things that really aren't clear cut and so you can give those broad definitions of things like viral cough for some of these things because yeah, it is a viral cough and sometimes it is difficult to tell the difference between them. Um Right. OK. So gonna move on to doing some stations now and then we will wrap up. Um Does anyone have any questions about what we have talked about so far? Um I know you've got time for questions at the end, but I'm just asking now because we're here now. Um There is AQ and a in the bottom right of the meter. If you want to ask anonymous questions, you can ask questions in the chart. If you want to ask our regular questions, I'm not gonna read your name out either way. Um But if anyone has any questions now before we move on to stations, this is a good time. Also, I drink my tea. It doesn't seem like anything's really coming through. OK. Remember a lot of these stations and stuff. I think I've, I said it to you in the first thing. If you don't wanna pay for a revision resource for SQ stations, you can ask something like chat GPT to do it for you. I think that they're very good. That's how I did the majority of my revision. Um So I appreciate that we um uh when we go through them, we only go through a few stations and I know that we've got a lot of feedback asking for more of them. I might put together just like a list of them, but it's just, I don't wanna keep you like, it's all really these sessions around for an hour and a half and I don't wanna keep, keep you for longer than that just to keep going through stations. Um Yeah. Um So that's what I'd recommend doing. And again, it's in the original slide document of the prompt that I give chat GPT of how to create it. Um If you filled in the feedback, I'm sure you can go find the slide deck on there. Um There's a question on here is the Sbar Station the same as Interprofessional communication station. Yes, but the title of the medal event couldn't be that long. So I had to just call it the Sbar Station. Um So yes, so the same thing. Um Yeah, but in all of those interprofessional communication sessions, they're always gonna ask them, can I put it again? Yeah. Um I didn't actually put it yet. It also gets um sent to you at the end when you leave. Um But OK, as long as we are all happy and no more questions coming through um gonna scoot on to doing a some stations here then. Um So starting off number 18 year old Mr Thompson has brought into primary care with a cough. You are the medical student that reviews him. Now, remember I said as we stand outside of the door, we are reading something that looks like this key things that we're looking at age of the patient cos it will tell us whether it's a pediatric patient age where we are primary care. What they've come in with this says to us, we are in primary care. So I'm not gonna say I'm gonna set up an IV in my management. Just bear that in mind, but it says cough and I know it's an eight year old. So, what are my diagnosis? What am I thinking about? Am I trying to get my head into gear for an eight year old? Why is that so small? An eight year old with a cough before we even take the history? Eight year old with a cough. What am I thinking about? Open cough? Yep, certainly could do, might be a little bit old for whooping cough, but I'm not brilliant at, for viral coughs. Asthma. Yeah, certainly could be. What's the other big one? Could be? Could be COVID. Yeah. Um, so the big one in kids, it's not asthma could be croup. Yep. 100%. Um, again, eight year old is probably a little bit old for it. Bronchiolitis certainly could be viral induced. Wheeze. Yeah. Any other ones, the, the, the differential that we've not gotten here. It was one that I got in my pediatric is the one that was specific to where I was and I added such like a last minute of just like differentials. And I was like, it could be asthma. It could be, uh, it could be bronchiolitis and it could be. Oh, yes, it could be. It doesn't just affect respiratory system this last one most likely in kids, but can be diagnosed in young adults. And we actually have a screening test for both. So, you'd hope the majority of people aren't getting to eight years old without being cystic fibrosis. Yeah. Um, so looking at a kid so, sorry, I just ignored the epiglottis pneumonia, upper respiratory tract infection. Yes, perfectly. So. Yeah, epiglottitis certainly could be. Um, I'd be very concerned, but again, that's why the immunization history is, is important, could be a pneumonia. Um, I want you to assess how unwell and upper root tract infection. Yeah, of course. Um, when I see a cough, I think of those bond or eight year old. Ok. I'm thinking asthma is a cystic fibrosis. That's what examiners like to ask about. Let's actually have a look at this specific history and see what they say. Um, sorry, I, the person in chat who said, can we post the feedback form again? Did you mean for this session or did you mean for previous ones if you could just answer that? Sorry, I just want, I might have just misunderstood your question. Um, as you're doing that eight year old male with recurrent episodes of coughing and shortness of breath is worth a, worth off worse after exercise. It is worse at night. It's not productive. There's no blood in it. No developmental concerns. They are fully immunized. No past medical history, drug history, no known drug allergies. No, family history of anything similar again when we point it out like this, just like I did with the previous one when we went. Well, it's not the previous one because Meghan was in the middle, but in the last one that we were talking about, they're really simple when you smush them down to just exactly what they're coming up with. Um, well, I suppose now that we've got this history, are there any new differentials or are we leaning towards one particular one in a cough in an eight year old? Worse at night? Worse after exercise? Any idea for this one? So we already set our, our rough differentials for it. Anything changed? We leaning one way or the other? Yeah, I, I'm leaning towards asthma at this point. There are some things that this patient hasn't got that. Maybe you might expect in a bundle history of asthma. The patient has no past medical history. Right. And the majority of time they, they'll go super bond or with these histories, like when they're easy, they're easy. Right. So, this patient will probably have asthma or eczema or their family will have asthma or eczema or hay fever. Um, did I just say past medical history of asthma? Sorry. Past medical history of hay fever or eczema. Um Yeah. So I at this point I'm now thinking, yeah, this is a, this is an a, an asthma type picture. So eight year old top differentials. Now, I think it's more likely to be asthma sort of to yourself or in, in the chat here. Remember you have to be thinking if it's that acute station four minute history, four minute skill or skill, might they ask you to do for this situation? You don't have to answer this. It's just worth getting into your head like they, the skill that you have to do has to be related to the person in front of you in some way. So we're in primary care but maybe an ABG in this in this patient might be, might be a good one, for example, just worth having. I think what might they get me to do? So we have this patient who we think has asthma, yep peak at strictly expiratory flow. Remember skill that people tend to forget explaining inhaler technique, make sure you know how to use the inhalers. They're in clinical skills. I will be on in our mock. This wasn't me. This was the other person that I walked around with um had to do, had to put on an ECG and didn't know how to do it. And that's fair enough. They put the, the stickies over the four valve sites and they looked at the rest of the leads and was like what? They just put them to the side. It did tickle me. So that was one of the skills. The other one was inhaler technique, explain how to use the specific inhaler. And I was like, God, if I had that, I would be shaking, I had no idea how to explain it. Um We have that one session with the pharmacist and they know it really well and they teach it to you and you forget it immediately. Um And this, and this person was so bold because the inhaler boxes come with a leaflet and the leaflet tells you how to take the inhaler. So they just opened it up and just started reading from it and it was brilliant. It was amazing. And I was like, this is so this is so bold and like, I didn't know how to write that on the feedback form, but you should learn how to do the inhalers cos it does come up, but also the inhalers tell you how to use them on them. So. Mhm. Um Right. So my question then in this situation, remember they'd ask you for the history, they then ask you what investigations do you want to send off in this patient? What do I want to send off for a patient with asthma? What investigation do you want? So remember you have to list these off. They'll ask you the way that I would structure them is the just think about what are those easy things you can do. So I think I told you last time, bedsides, bloods, imaging special tests. So yeah, at the bedside, I can do a peak flow me measurement. I'm not sure if me as an F one could do fraction, exhaled nitric oxide, but I could say it. It's, it's probably what I describe as a special test. Spirometry. You can do it at the bedside. Yeah, any bloods we wanna send off patient query asthma. I'm not sure what P FT is, is that, are you saying peak floy or am I, am I being exposed to a new test? Um ABG Y uh respiratory exam? Yeah. A res the examinations, I fall into this trap all the time. The examinations are not investigations and they do get annoyed at you for saying them. Um but yes, you would wanna do a respiratory exam on this patient. Um bloods um imaging. Yeah, certainly eosinophilia um on FBC. Remember as well. We don't get a chest X ray for imaging. We we also don't know that it's asthma. You do wanna make sure that we're ruling out other things. You can also get breathlessness with anemia. Um You can also get breathlessness with a pneumonia. So we do wanna see those white cells, the C RP um if they were slightly older, I might be thinking down the route of a pe but does it sound like exercise induced pee Mm. Yeah, bronchodilator reversibility. So as part of your spirometry and yeah. So bedside bloods imaging special test, I would read them out in that order as I would be going through. So in terms of bedside testing, I would be considering doing a peak peak flow measurement, BP and do oxygen saturations. Um uh bedside bloods. Um I would like to send off an ABG as this patient is acutely unwell. Um I'd like to send off a full blood count um with CRP. Um I'd consider doing blood cultures, but I don't think this patient has sepsis at this point. In terms of imaging, I would consider a chest X ray and in terms of special test, I would consider spirometry with bronchodilator, reversibility and fractional exhaled nitric oxide. Can you see I've talked through them and I've talked through them in a structured way. So the examiner can really go walk through with me and like making sure I'm covering all those aspects. Scooch, move that out of the way. Let's have a look then what have they given us? And by they, I mean me cos I did this. So they've given us a spirometry. So double check that your patient is your patient. I've just put a access cos I was feeling lazy. Um in my mock in January, January, I think it might have been January for my um on one station, I interpreted the spirometry of the results that I had perfectly my, it was the best interpretation of data I'd ever done. Um II got a red flag for it because I didn't check the patient details and they tell you immediately after the end because you had that discussion at the end of the mock. Um they were like, yep, brilliant interpretation, but you didn't check the patient details. So this would be a safety alert. And I was like, oh, and they were like, don't worry, this is the time to do it, but you, I promise you you'll never do it again. I was like, that's so reassuring. Thank you. And I walked in the next room, my might want to do it again. Abdominal X ray, I interpret the abdominal x-ray and I don't look at the bloody label and they're like really good interpretation. Um But this would be a safety alert and I'm like, because of the name because I would never make the same mistake again, but I instantly made it. Um So learn from my mistake. Now, read the name. I will always read it out. Now in my excuse, I say this, these are some spirometry results for Mr Thompson. Date of birth, blah, blah, blah. I'd like to cross reference that with the data from the patient and then I'd look at it. Ok. Um So what are these, what's the spirometry showing then I'll pop this up here. Oh, there we go. What's that spirometry? Sorry. Yeah, certainly is God I hope you're the same as emergency boys. I really respect to the baby. Um Yeah, this is an obstructive picture. So how do you go about interpreting this and talking it through again and we'll go through data interpretation in January. But the way that I would do this one here is I would say the they've given you acronyms, not things, right? So I'd be like the forced vital capacity is 1.2 L which is low. The forced expiratory volume um is 0.7 which again not is low. So it's normal force expiratory volume is 0.7 which is low. And the F UV one to FBC ratio is 58% which is low, which is an obstructive picture which points towards what, what do we think it is asthma? Yeah, it points towards my main no of asthma. Yes. Um So that's exactly what I would say. This is an obstructive picture which supports my primary differential diagnosis of asthma. Be confident with what you're saying when, when you're confident in it. Um Yep. And so lastly, then the question would be, how do you manage this patient? So question, how do we manage asthma? All the important bits that we need to include and I've included a, a script of how I would present this on the next slide. So if you include something that uh I haven't, I'm just gonna say you're wrong. I do appreciate that. You're probably not revising actively for respiratory at the moment. So I'm not expecting brilliance that salbutamol inhaler. Yes. Exactly. I think that's probably the mainstay of it. Anything else that we add on, either in the chart or on the, the chat function steroid? Yep. Perhaps a steroid. I see. Yes. With an inhaled corticosteroid. We would use a pediatric low dose, inhaled corticosteroid. Yep, and check if they need to be admitted. So, yeah. Do they have a severe asthma attack? Uh Like I didn't ab acknowledge it in GP we don't actually want to be sending that away. Um So I can, I can see some people are dropping off at the moment because we're on the uh we're coming towards the end. Um I just wanna ask a, a question in the poll and chart um of essentially our next session is due to be next Wednesday, but I do appreciate um that it's the beginning of the winter holidays. I just wanna know whether people are gonna come or not. So if it was next Wednesday, could you just pop in that chat? Whether you would actually come or not or if I should move the and Gyne one afterwards, Sabra and I CS and chat? Yeah. Thank you. Um and peak flow diary. Yeah. Brilliant. Good job. OK. So just whilst people are answering that and we'll see what the general vibe is. If, if the majorities know, then I'll postpone it. How do I manage this patient, I would present it in like this, my most likely diagnosis at this point is asthma. So I will describe the management of asthma. Why have I said that? Well, in all of the EK Ses I have ever done, they have always said given the most likely diagnosis of X, describe the management, right? Um So when I said, oh, this patient is healthy or whatever and they were like um this is CO PD. Um they, II don't just randomly describe the management of a health patient, right? They'll tell you, I've put that just in case it's not. But this is how I would say if they didn't say my emotion I di diagnosis at this point is asthma. So I will describe the management of asthma to begin. There needs to be a conversation with Mr Thompson and his parents about what asthma is and explain their role in the management of his symptoms. This will include his inhaler technique assessing for and avoiding triggers and how to take peak flow measurements. In terms of medical management. Given his age, I would like to give him a saber and a low dose pediatric I CS, for example, a salbutamol inhaler and a beclomethasone inhaler. It's important to explain the side effects of this management as well, including the increased risk of oral thrush. He will also require a referral to the asthma nurse team who will support him going forwards. He will require regular follow up and medication review with a view to increasing his medications. If his symptoms are unmanaged more long term, he should be considered for an annual influenza vaccine and pneumococcal vaccine every five years. The important aspects of this history of this uh summary, sorry that I want you to take away when it comes to writing your own scripts or thinking about them in your head is that I've talked about the patient, I've talked about the medication, I've talked about the MDT and I've talked about long term patient medication MDT. Long term, the majority of stuff is not managed by just you a medical student and GPI don't know if you know that. Um So it's got to be somebody else at some point. And long term, my long term hair, I've talked about vaccines. You can talk about anything. But the idea is I'm talking, I'm thinking about the patient in several aspects. They're not just isolated representation of their illness. OK? All right. Any questions about that chat, please do put them either on the Q and A or in the chat. Um And we'll go through them. If not, I'm moving on to case two, but I'll just wait a moment to see if anyone comes up with any questions. OK. All right. Then, so 13 year old Miss Denver is brought into primary care with a rash. You are the medical student. The review. So then, so our question is again, we are standing outside of that station reading that. And we're thinking, well, what do I think it is before I go in? I only have the information of rash. What differentials am I thinking for rash in a 13 year old, 13 year old rash? What were we thinking? I think this is worth talking through trying to get this, that sort of that first step of trying to figure out what the diagnosis is before you go in because if I'm going and standing outside that, that room thinking it's, it's meningitits, it's meningococcal or it's meningitis and that's what I'm thinking. Top three diagnoses. I wanna make sure that I'm asking about what headache, neck stiffness, photophobia, right. Yep. Could be eczema, chickenpox measles. Certainly these are all very important things to come up. HSP. Yep. I've literally, I've seen a patient with HSP literally this week. Um I don't know if you have random HSP person. Um ITP. Stop. You'll make me cry. Um Yes, honestly don't worry too much about those really rogue ones. Like I'll be honest when you that taking that history, what's, what's the really scary thing that looks like? Itp looks like men, meningococcal septicemia in a kid. So maybe they feel tired. They've come in with this rash. Yeah. Could be meningitis. What's the thing that we get ready? Anyone though? Yeah. A LL. So, yeah, like leukemia is the, is the bad one and the history for ITP. Sounded like a LL to me and that's what I said was my primary diagnosis. Um, and I've not put a ll in the list of diagnoses, but when I see what appears to be a bleeding disorder in a, in a kid, I'm like, oh, II don't really know what it is. I did say ITP is a differential but I had no idea what it was then they were like. Yeah, good job. I was like, damn it. Um Yeah, so II wouldn't worry too much um about those really rogue diagnoses. Um So yeah, scarlet fever, definitely something that could come up. Um Might even be a, like a more of a cardiac focused. I didn't even talk about the Kawasaki disease. Yep. Certainly think about it with a fever, five day fever, leukemia, eczema herpeticum. Yeah. Eczema herpeticum is actually super rare. But yeah, if you got like a super, super itchy, rapidly advancing crusty eczema rash. Yeah, certainly. Um Yeah, brilliant. So standing outside there, these are the things that I'm thinking about. I'm crying because of the ITP. But like a lot of people are coming up with the meningitis. We've also got those viral rashes that have popped up here, viral infections, eczema chicken pox, just a general virus HSP. We've got some more vasculitis looking pictures over here as well. Yeah, that's what I'm thinking about going in. So as I'm standing outside there as well, I'm just thinking, well, it's a 13 year old, this is a pediatric history. I'm gonna safeguard and I've got to think about those differential diagnoses. So let's look at the history then and see which way it points us. 13 year old female rash appeared yesterday, started on her trunk spread to her arms and legs, small red spots that don't blanch. It's not itchy. No blistering. Generally unwell with a fever and a headache. No. Past medical history, drug history or allergies had measles as a child. Father had itp. Clearly, I was feeling masochistic when I did this. So with that in mind, most likely diagnosis with a rash that doesn't blanch, not itchy fever, headache. Put this here. It's like a little one. There's a few what I would describe as red flags in this. Yeah. II think so. I think this sounds like a meningitis picture. A few red flags in this had measles already. So now I'm thinking about measles, but I don't know that much about measles. Father that I to be. Does it sound like itp? Would I feel generally unwell with itp? Maybe not. Um, yeah, fever and a headache. I'm thinking about meningitis. And again, when we're talking about meningitis, we wanna make sure if this has got small red spots that don't blunt, what specifically am I talking about? What causes this meningitis? What causes that type of meningitis? Somebody said it earlier. Yeah. Hopefully this, I think this is a really like big thing where I think a lot of people think that meningitis and meningococcal septicemia are the same thing. This is meningococcal meningitis and it's meningococcal septicemia. Meningitis is inflammation of the meninges due to anything. It can be due to autoimmune. It can be due to a virus, it can be due to a bacterium. Meningococcal meningitis is meningitis caused by meningococcus. And the meningococcal septicemia is when you've got meningococcus in the bloodstream. Most likely because you've got meningococcal meningitis, right? So, just make sure that we're including that as a, as a thing, right? This is, we're not saying this is a viral meningitis. We specifically think that it's this one type, right? And it's the most likely one that they'll tell you about. Brilliant. Sorry. I've just noticed that there's a question. How do I see it? Uh Is the po Yes food? Oh, that's a good point. It's really weird. Right? But my poll is meant to be our next session is next Wednesday. Would you come? Yes or no? Sorry. Um It seems like it's majority. Yes. Um All right. So yeah, we're thinking down the route of meningitis. Do, do what skills might they ask you to do again? This is more for just your own sort of preparation of just thinking any, any condition that I've listed on here, any condition that you think it is worth revising. I imagine all of your right flipping itp on your list of things that's worth learning now. And it's not, it's not well learning. Um But when you look at them, you have to think well, if this was in a, in an Iski, what skill would they ask me to do? What investigation would they make me interpret? And the more you get into that, the more you get into the mindset of somebody who's creating an Iski station, the better off you will be. Um So what skills might they ask you to do? You can answer that and chat and think about it to yourself. Um A lumbar puncture. No. Um but this is probably gonna be like a blood culture one. You could do an ABG in this one here. You could do a cannula in this one here because you're going down the route of maybe sepsis. Um Why would I say you, they might ask you to do an IM injection? Why, why they ask you to do an IM injection for this case? Yeah, exactly. We're in primary care and it, this become relevant when you look at how I phrased it. But yes, it's for the intramuscular benzyl methyl penicillin stuff, right? Where we're gonna give that intramuscularly. If you were in the hospital, you don't give that Im and I think that was one of the things on the recent progress test where you don't give im penicillin. If you were presented to them in A&E, you would just give it IV and you treat empirically for meningitis So, yeah, good job. They could ask you to do that. Um, cool. Ok. Um, right. What investigations do we want? Then again, let's think, start off with bedside, what bedside investigations do we want for meningitis or for this case generally? Because we don't know. It's, yeah. Um, I meant to say earlier actually, um, I included in my space. I said, what was it? SABA, don't, don't abbreviate stuff as much as you possibly can. Um, so you should say short acting as much as you can. Don't shorten down stuff. Um, it sort of just comes across as a little bit lazy to the examiner. Um, and you have the time to say it right. Um, so yeah, as best you can don't shorten it down. The reason I'm saying it with this is that if you say I'd like the basic observations, I'd probably list them. Um, so I'd probably say I'd like the basic observation including, and I'd list the important ones, my heart rate and I want my temperature and BP. Yeah. Glucose. We have this kid with a headache and a fever and I don't know any of their history. Throat swab. Yep. If we're giving you like a, a group, a sort of picture we certainly could. Um, yeah, bedside. So bloods, somebody said FB CCR PU and E FT at this point, they might then ask you what are you looking for on the full blood count. So, when I read out my bloods, I would say like specifically what I'm looking for and, or at least one thing that I'm looking for for all of them. I'm looking at a full blood count because I want to see if the white cells are raised. I want CRPS. It's a marker of information. Like I just give it a little bit of, of detail for it. Blood cultures brilliant. Um Again, people said uh ABG before certainly. Um blood cultures, ECG Yeah, I'd put ECG as a as a bedside test. Um But yeah, lumbar puncture, I'm not saying this wrong, but I'm not sure why you're in culture in this patient. Um And you've said there in that one there. Oh PC. Yeah. So if lumbar puncture, if no raised intracranial pressure, what does that mean that we need before an LP ICD head? Yeah. Use CT head before you do an LP um especially in this sort of picture. And we tend not to do lumbar punctures at all in, in meningococcal meningitis. OK. Brilliant. So, yep, II agree. These are the generally the ones that we'd want to do lumbar puncture being that special test that we want imaging being the CT head. I agree. Let's scoot you back over here. Um And let's have a look at what we have to interpret them. So, patient blood test results, can anyone tell me what's wrong with this? These blood test results? So we don't get red flagged? In or anyone know our patients are like a 13 year old girl, isn't it? Mr Bloggs doesn't exactly line up with the patient. So again, I'd say this is, these are blood test results for Mr Bloggs. Date of birth, blah, blah, blah. I'd like to, I'd like to compare that to my patients details. And then for this one, I would say, I don't think this is correct and they will say, OK, interpret the results anyway. And so we would interpret the results anyway. Um So question being, what do the results show? Put this here in ch oh on the venti? OK. So somebody's written a normocytic anemia, thrombocytopenia infection due to white raised white cell count and neutrophils. OK. II agree. Uh high white cells, neutrophils low. Hb Yep. Um Again, when I'm talking this through, I would talk it through from top, top to tail and then summarize with a lovely sentence like this one here. So looking it through the hemoglobin is low, the white blood cells are raised, the platelets are low. The mean cell volume is normal, neutrophils are high and the lymphocytes are normal. So overall, this is a picture of a normal cystic anemia with thrombocytopenia with raised white cells that is predominantly a neutrophilia. I think the only thing that I'm thinking here is that. So yeah, I would probably say something like suggesting infection rather than this is an infection. Um because well raised white cell counts. You can also have that in um in blood cancers, can't you, it doesn't have to be due to uh infection. But given the clinical picture, it suggests infection. Yeah. Um So just, just bear that in mind. I don't think they'd be super pedantic about it unless it was the wrong diagnosis, right. Um uh But yeah, brilliant. Anything here. Yeah. Excellent. Low platelets. Yes, we've talked through all of it and then if you're really confident, you can say here, flick this reports, my most likely diagnosis of meningococcal meningitis. Um ok. Um So somebody's asked why are we doing a lumbar puncture or a CT scan in this patient? Um So a lumbar puncture in itself, we can use to identify the specific organism. Um and indeed the presence of an infection at all. We are ident. We, we're suggesting that it's meningitis based on a clinical picture and it is predominantly a clinical diagnosis. But the stuff that's happening in meningococcal meningitis is essentially disseminated intravascular coagulopathy, which is this low platelet uh that is causing this widespread bleeding which causes these little the rashes that we've got. Meningococcal meningitis is not the only cause of this particular rash. It's not even the only cause of meningitis that causes it. So, from that perspective, although most likely cause meningococcal meningitis, we're not gonna go in like you, you can't say for 100% with 100% certainty that it definitely is that cause without having the lumbar puncture, you can't do a lumbar puncture without a CT head because a CT head will show us whether there's raised intracranial pressure, which you can have from a variety of different reasons including meningitis. Um But also if you've got any other causes of it, if you've got an intracranial mass, other things like that, if you take a lumbar puncture on a patient with raised intracranial pressure, you suck stuff out through a tube and you create this pressure that allows the brain to escape downwards. Cos remember it's like huge pressure up here. So it will squeeze downwards that's called coning. Um and you'll kill your patient. So you will do that in an ideal world. We would always do our lumbar puncture before like as well as blood cultures before we start antibiotics. However, we wouldn't delay starting antibiotics in favor of getting an LP or blood cultures. It's way more important that we treat the infection and the patient doesn't get worse than it is that we know specifically what it is that causes it. I have a patient with what I think is meningococcal meningitis and I treat empirically for that and it doesn't help. Then I need to start considering another diagnosis anyway, I hope that answers your question again. Feel free to ask questions both in chat and on the, the me, the mentee as well. Um So yeah, this, yeah. So what's the management then? So then that's the question. How do you manage meningitis and remember, consider the environment that we are in, we are in primary care. Yeah. Well, yeah, like, like everyone said above already, we're in primary care. So we're considering giving that intramuscular bin, right? Um So yeah, what we've got here, IV, cefTRIAXone. Yeah, I think I agree with this as, as a GE on the GE as a, as a general management for it. Um, the actual stuff in itself that we give will vary hospital to hospital. Um, so just whenever I'm gonna give specific antibiotics, I'll always say I would treat according to local guidelines. What I've been exposed to is to treat with IV cefTRIAXone. We can't give IV Ceftrixone until we get transferred to hospital. Yeah. So we give the II M stuff transferred to hospital. Dexamethasone is something that we can give in meningitis, but we actually don't give it in meningococcal septicemia specifically. Um Yeah, I don't know why, but it reduces the inflammatory response as a whole. That's why we use it. Um, but you're not, oh, you're not supposed to use it in meningococcal meningitis because of, um because you've got, we've got this D IC stuff going on and so it's gonna make that worse. I, yep. So again, if I were gonna ta talk about the, the management of this patient, this patient isn't less than six months, but that's definitely worth talking about. You would also give amoxicillin to cover for Listeria if they are young or very old. Yeah. Contact tracing and notifying public health. Yep. Again, this old picture of meningococcal meningitis. We need to make sure that this is a notifiable disease and we need to make sure that we've spoken to other people. Urgent transfer to the hospital at E assessment. Yeah, brilliant. I have antibiotics while awaiting IV fluids and oxygen if needed. En route. Call ahead to the pediatric hospital. Yes. Do your sbar brilliant. Um Let's have a little look or did I just again, this is like, you don't have to say this is that same thing and write it. However, it's useful for you. My most likely diagnosis at this point is meningococcal meningitis with potential septicemia. So I'll describe the manager. This, this will begin with an explanation of the diagnosis and management of the patient to ensure they informed. But this is an emergency scenario. Why am I saying that I'm saying that because like I can't sit here and describe what meningitis is in a lot of detail because this patient is critically unwell. First, I get my senior involved as I'm just a medical student. If you've got something, that's scary. What would you do in real life? You'd get your senior. They're likely in management or referral to hospital. In the meantime, as we're in primary care, we can give a stat dose of iron beds or penicillin provided the patient isn't allergic. They said they had no known drug allergies earlier, but we still double check. We can also see what aspects of the sepsis. Six, we could start in primary care, for example, taking a blood sample for lactate or blood cultures and also consider pain relief for a headache progressing at the who pain starting with paracetamol. Would you actually take a blood sample for lactate and blood cultures? No, but again, why have I said the sentence I wanted to put in sepsis? Six, I haven't even included the stuff on contact tracing. Um But yes, certainly that's the four things, right. What am I going to say to the patient? How I actually got to manage it? MDT is there going into hospital? And the last one being long term, long term is the contact tracing bit. Um Right. Please continue to put questions in the chat or in, in um uh ment if you like we are gonna do this last one, last case. Ok, 15 year old Miss Bender is brought into the emergency room with abdominal pain. You're the med student that reviews her as always, you're standing outside that pa that that station patient, abdominal pain. 15 year old. What were we thinking after pain sucks. Yes, it it's gonna be the first thing I was gonna say if nobody said it, we've been talking about specific pediatric conditions, right? Just because somebody is a child does not mean they can only present with stuff that typically affects Children. Right. So, you also want to make sure that we're thinking about other causes of abdominal pain, ectopic pregnancies, appendicitis, ovarian torsion. Certainly. Anything else. Yeah. Mesenteric adenitis, certainly. Why are people chanting at the pub across the road? What's happening? IBD? Yeah. Again, we typically think about that in, uh, sort of young adults or middle aged adults. Pelvic inflammatory test. Yep. Equally. Uh, yeah. Um, it's easy to sort of also go down sort of one route. Like once you think about ectopic pregnancy, it's easy to go. Oh, ovarian torsion, uh, ovarian cysts, pelvic inflammatory disease and ignore the rest of the abdomen. But it's good. We've got quite a few different options here. Anyone on the chart? Uh, appendix and obstruction. Yeah. Brilliant. Good job. Um, especially remember if they've had surgery and we are gonna ask about surgical history too. Cool. We'll smudge over. Uh, let's have a look at what the general history is that they have got 15 year old female abdominal pain and bloating for the past few months having diarrhea over the same time. It's greasy and frothy. A weight loss of 7 kg over the same time, feeling tired, trying to eat and drink. Normally not dieting. No trigger, no blood, no vomiting, no past medical history, drug history or uh, allergies. But mom has ulcerative colitis. So, now we've got this history. What are we thinking? Abdo pain, celiac. Yup. Anything else? Yeah. See that disease brilliant. Yeah, it could be Crohn's disease. Yeah. Certainly interesting that you've put Crohn's disease rather than ulcerative colitis. I agree with you. It's much more likely to be Crohn's and ulcerative colitis. Can anyone in chart? Tell me why, despite the fact that we've got a family history of osteo colitis and the ideas. So, basically the reason this is much more likely to be. Yeah. Yeah, much more likely to be Crohn's disease because there's no, there's no blood in the stool and also that it's caused weight loss. So Crohn's disease is more likely to cause weight loss because it can happen anywhere in the bowel which includes uh which can result in malabsorption. Um And if you've got malabsorption, then you've got weight loss, ulcerative colitis is very unlikely to result in weight loss except for just the general diarrhea. So it tends to be very unlikely. Um Yeah, good job, I agree. Um I think this is in this case here, more likely to be celiacs, which it seems like the majority of people agreed with it. It's only when I'm pushing you for other diagnoses that you're saying other things. Um Remember we do wanna come up with differential diagnoses, like I said, unlike other osk examinations, we don't have to give like three. We just need to give what we think the differential diagnoses are. I always aim to try and give two differentials. So my main one and then two others which is three total, but it's ok if you can't come up with them. Um, even if the last one is really, like, if you think it's very unlikely I would say that. So, I think my most likely diagnosis is celiac's disease because they've got abdominal pain and bloating with greasy, frothy diarrhea. Um, uh, another potential diagnosis would be Crohn's disease. Um, uh, but it's a, it's an unlikely age group. Um, but it's still something that I would consider and a viral gastroenteritis, but the patient isn't vomiting, for example. Right. So, we've got our, our new history or our new sort of thoughts of, oh, this might be down the route of, um, celiacs. What skills might they ask you to do again? Just think about this for all of your differentials just making sure that you're thinking about all of them. We've got a patient with weight loss. This could be a glucose. This could be taking blood cultures. Um, what else could it be? Height and weight? Very few people revise, height and weight could be basic obs as well. Um, what investigations do you want for this patient? 15 year old celiacs bedside, blood imaging specialists at the bedside. What were we thinking? Yeah. Not sure. I'd be doing that at the bedside, but sure. Yeah. Um, yeah. So that blood is a blood test or special test. I'd probably put that under for sure. Yeah, we need to do an anti T TG. And you have to do an anti TTG alongside a total IGA or you can't interpret the anti TTG. The lab will actually reject the anti TTG if you do that. And the me, what is, yeah, wanna make sure that we got our basic observations for the patient, right. We've got our news chart filled in, like I said, probably would want a blood glucose. She's lost weight. So we want to weigh her in terms of other bloods. What's important to do in Crohn's disease or even in Celiacs, why, why is the patient losing weight if they've got Celac disease? Yeah, exactly. So, they're probably gonna have malabsorption. So you wanna make sure you're doing your iron and your vitamin. So, so looking at B12. Exactly. Um Yep. Um, as a result, I would also probably want to do a full blood count. I want to look at the hemoglobin and the mean cell volume because if we've got either one of these deficiencies, then we might have an anemia. Um, also want to like, again, general health of the patient, they're losing weight and I don't know why LFT S uh T FT S and EUS, I'd also wanna look at C RP because they're tired all the time. Do they have an underlying grumbling infection or some inflammation somewhere? Um, imaging? What, imaging, what you wanna do? Stool sample. Yeah, pregnancy test. Yeah, we had a lot of ectopic pregnancies popping up. Um B12. Philip Yeah, endoscopy, abdo x-ray is probably the one that we'd start off with. Yeah. Um, what, how do you actually diagnose celiac disease in the chat or? On? Um, yeah, exactly. So, it's gonna be the, you may want being in internal biopsy. Um, yeah. Um, is that gonna be the first line thing that we're gonna do? No, but it is probably worth being aware or like letting the examiner know that you're aware. So later down the line, I would consider doing a internal biopsy. Yeah, certainly. Um Yep. So what did I, what have we put on here to do? Um Here we go. I actually thought this was really mean to do at this point here. So I've just put the interpretation next to it. We'll do data interpretation, we'll do imaging at some point, but this is a normal abdominal X ray. Um So what have I talked about here on the left hand side again, we will talk about this at some point, but we're looking for any evidence in here. What can you actually see on an X ray on Abdo x-ray? Not much. You can see fractures and you can see big obstruction if it's big. So, the real question about the bowel is, is this and that a problem? And the answer is no, why is this and that? Not a problem? Well, I look at it and I think, hm, how come I can see it there? But I can't see it here and that's why it stands out to me. But when I actually look at it and I look at how big it is. This is not very, this is not very large. Remember you've got that 369 rule for obstruction. This here is around the outside, this is large brow. So we'll be looking for six centimeters and I don't have any way of measuring this one here, but that does not look six centimeters to me. If I think about how wide the, the vertebral bodies are, that's not six centimeters. So that's not obstruction, that's not obstruction over here. So this is just gas in the bowel as a result. There's also no evidence of obstruction. This doesn't look huge, then no dilatation. And then I go around each of these. I think pelvis is quite difficult to actually interpret for fractures because it's got all these like weird lines that tend to look like fractures. Maybe that's just me. I don't know. But the thing that I just think is with the pelvis, you've got both sides compare them. So I'm like, oh, what's that? Oh, it's right there. That's fine. Um Oh, what's this? Oh, this right there as well. Yeah. So just make sure that you've got it on both sides and there we go. So this is a normal x-ray. Does that dissuade me from a diagnosis of celiac disease? No, I wouldn't expect an abnormal x-ray unless the elate disease had progressed to an obstruction or a rupture or anything like that. But we will talk through how to investigate these. This patient's also got this. No. Am I concerned about this? Does, does this person put something in themselves? No, this looks like it's most likely a, uh, like a button on a belt, right. So, how do you manage this patient? Celiac? Oh, I said, how do you manage, man? How do you, how do you manage Celiac disease? Yeah. Oh How do you manage Celiac? That's closest we can get education, gluten free diet. Yeah, brilliant. I remember we're thinking about patient medical management MDT and then like long term stuff. Um So yeah, the majority of this stuff is just gonna be the patient education side of it. Are we gonna do much from a medication perspective for Celiac disease? There is probably one thing that I might give. That's not uh I value this so much. There is probably one thing that I might give long term. Definitely. Yeah, vaccines, pneumococcal. Why they're functionally hypersplenic. So, yeah, in the meantime, this patient had weight loss, feeling tired all the time. What do they, what might they need? Maybe some supplements, supplements. Not how I would describe it really, but I suppose, yeah, I just wanna make sure that they don't need iron and they don't need B12. And can I in this patient? How should B12 be given to this patient? How do you give vitamin B12 replacement to a patient with celiac disease? Any ideas? Yeah, it is. It is an intramuscular. Do you, does anyone know why, why we couldn't give it orally? So, it's based on that thing of why didn't they get it in the first place? And they didn't get vitamin b12 in the first place because they had celiac disease, affecting the small intestine, they couldn't absorb B12. So, until we've completely got rid of the, the celiac disease, like the, the actual villous atrophy and everything. So it's resolved and they're on a completely gluten free diet. They're still not gonna be able to absorb vitamin B12. I'm saying it's because a lot of people think that the only way that we give vitamin B12 is I am because the other situation that we would give vitamin b12 in is when do we give vitamin b12? That's the other thing that we need it for pernicious anemia. Yeah. Again, we're not gonna give that orally because the reason they're not getting it is they're not absorbing it. So it's just worth bearing in mind that unless the patient has a problem with absorbing it, we can give it orally. It is incorrect to give. I am like I don't have celiac and I don't have pernicious anemia. If I was deficient in B12, it would be incorrect to give me I am um B12. Ok. Um And that, that comes up. So I just wanna point out because I see a lot of people get it wrong because we learn about it in the context of pernicious anemia and just sort of assume that's how we give it. But no. So, all right, we've talked about it. I appreciate we're going on a little bit. I really need to be. So my most likely diagnosis at this point is celiac disease. So I will talk to the management of this. So we'll begin with an explanation of the diagnosis and management of the patient to make sure they're informed, they'll need to start on a gluten free diet and therefore need education on what gluten is and which foods are likely to contain it. For example, they should be avoid, advised to avoid wheat and barley, including for example, bread and beer. It would be important to check for and correct any vitamin or iron deficiency that may have contributed to her tiredness. Patients with celiac disease have functional hypersplenism. So they will require a pneumococcal vaccine and a booster every five years, right? That is the end I'm gonna send through our feedback form here. Um And I'm gonna send this through here. Once you've done the um uh the feedback form will upload the recording and the slide deck will all go up there. I know that's a question. Everyone has all of the time. Besides that, we've got ready for questions in the chat, ready for questions in the Q and A section it, it might be on the bottom right hand corner. I think I'm not really sure. Maybe at the bottom for you guys. Um, any questions from anybody, um, about anything we've covered, it seems like generally people are ok with the session next week. Um So we might go ahead with it. Um Any questions about pediatrics? I appreciate that. We've only gone through how to answer the questions, how to structure your answers and what questions to ask. We're all good people are slowly dropping away. Thank you for the for, for this question and chat. I appreciate that big time. Um I hope you guys are finding them useful. I just think that it wasn't the, the stuff that we're given isn't brilliant. So I ii hope that it is actually useful. Um There's a lot of smoke going up the butt. I don't really know how to use that, that phrase in a sentence. But yeah. Um You're welcome. I hope, I hope that things are going good if you can't come to next week's session. I hope that the holiday goes well, the little break that you have and it is a little brick as well, isn't it? So like two weeks? Well, I will hang around just in case. Ok, I think I might just be left with the people who have left me talking in the background whilst they had a nap. So I think I'm gonna start to shut this down now. Any questions that you wanted to send, please be free, feel free to email me about it. I'm happy to answer anything, but if not, thank you all for coming. Um and enjoy the rest of your week. Hi, everyone.