Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

All right, welcome everyone. We'll kick off uh session nine. So today we will be going through handover and prioritization. And uh just before I hand you over to Nick, I was gonna talk you through the session today. Um Just an update from my side is the session, uh the next session. Um So the last session before we do the recap because of uh lack of availability of tutors that's been pushed back to the 21st of Feb. So we'll have this session and obviously psa is coming after this. Um And then we'll have a break for around a month and then the last session of the program will be on the 21st of Feb and then we'll have a revision and recap um after that. But apart from that, there's nothing new from my side. So I'll hand over to Nick and she'll talk you through handover and prioritization with some cases. So I guess that can get involved and then uh uh cases and uh questions at the end and we should be a quick one today. So, um it should be done by sort of 10 past eight on the latest. Hi, everyone. It's good to be back. Like time has gone very, very quickly since the last session. I can't even remember when I did the last one probably in November. Um But welcome. Thank you all for coming. Uh So yes, as s said, it's handover and prioritization today. Um I think this is probably one of the, one of the most challenging AK stations, if not the most challenging, if I may say so just because this is testing a lot of things in one go. Um And this time pressure, it's just, it's, it's quite a hard station. I've personally found this very, very challenging and by no means, any advice I give today is something that I did perfectly on the day. Um This is just something that I've learned coming out of the station. Oh, I could have done this, I could have done that and then also working as well as an F one has definitely put some things into perspective. So yeah, just introduce myself. So Lester grad, I probably know a lot of, well, not a lot but some of you, most of you um currently working in London right now and I'm on urology at the moment. Going on to au next any questions, even career advice, let me know towards the end, but we'll get on with the session. So try and make this as quick as possible. But also if you need me to slow down, let me know. So handover and prioritization. I'm gonna take control, submit if that's OK. Um With the slides. So OK, handover and prioritization. So what is the station about? So um with stations, I always try to set the scene so that you're not flustered. Thinking about where am I going? Where am I sitting? Who am I talking to? Do? I need to move, blah, blah, blah. I think it should be very clear when you're going in what's going to happen because I remember for this station, I kind of walked in and I was like, what's going on? Where do I sit? Who do I talk to? You just get really flustered. So, so let me explain the layout. The stations, basically, they're, they're linked together and you walk into a room, you have a table and two examiners sitting right in front of you. Um And each examiner will take a station each. So the first stations handover, you are one examiner who will do the handover and then you'll have, then it will rotate to the next person, um who's sitting next to them and they'll be doing 16. Station, 16 is the prioritization. So they'll be essentially asking you to explain your reasoning. Um You'll have the two minute reading time for the first station. You'll have the two minute reading time for the second station. So, but the, the key, the key thing is you're staying in the same room as at least that's how it was for me, I was in the same room just sitting at a table with two examiners in front of me. Um I hope that's clear. Any questions about layout, please feel free to pop in the chat. Um I'm just trying to see if I can see the chat. Yes, I can. Ok. So, um hopefully that's clear we will move on to the Mark scheme. So actually guys, the mark scheme is quite good. It pretty much tells you what they're looking for as it should. Um But it's more just how to make yourself stand out from what you would perhaps usually do and how to, how to be better at sort of going about the station. Uh So it won't go into too many details. But essentially if we start with the first part, the handover, um this is information gathering, ok? This is about getting as much information as you can. Um So you have to sort of ask some specific questions that relate to each patient, but there's also questions that you need to ask that are context specific. So you'll always ask them. Ok. Have you examined, have you done these investigations? But you need to be more specific, like, well, have you done this investigation? So you, you need to show your, your knowledge. This is about showing off your knowledge, both parts, but especially this one, it's about, you know, are you developing a working diagnosis? Are you screening the presenting complaint with all possible differentials you can think of, you need to ask key questions. So information gathering, good questioning. Um and uh it has to be patient centered as well. So you have to think about verbal nonverbal cues. I mean, my examiner didn't give any nonverbal cues. So I wouldn't always rely on that. But if they are, then by all means, you know, question them and ask them. Have you done this? Are you worried about this blah, blah, blah? Um It says risk stratification as well. So I think for that, just think s see your early warning score. Um Again, we'll go on to it, but your early warning score is just a number. Um So do not rely on that solely. It's about the full clinical picture like with anything. Um But it always does help in guiding decision making. So risk strategy use the score to your advantage. Um And then professionalism. So that just basically means being engaged, being inquisitive, probing them, asking them as many questions as you can. Um And not judging, I mean, ii wouldn't assume any of you do this anyway, if, if the exam, if you said to them, have you done this? And they said no, I II assume no one of you would frown or, or judge that. So, but it's just about being engaged uh and asking all the questions. So that's handover. Um The second stage your prioritization, it says recognizing who's unwell is the key thing. OK? Um And demonstrating your knowledge. So saying, OK, this is what I'm gonna do, OK. This is how I'm gonna manage this. This is how I'm going to further investigate. This is testing your knowledge. Um And then also a big one is using your team, which we'll go on to when I go into details about tips. So making sure you use your team and delegate tasks appropriately and then obviously giving a nice summary for the examiner saying, OK, so this is my priority list and this is why, so that the mark seems really good. Uh look into it. It'll give you a nice idea of, of how to go about the station. Um uh Keep asking any questions if you need to. So top tips then um so yeah, so the Mark scheme has a lot of tips in it, but I just sort of want to summarize it in a nutshell for you guys. So handover is a very information heavy station. So the reason I said it's challenging is you, you're getting a lot of info thrown at you, but you also have to think at the same time as to what more do I want to ask. So it's quite, it's quite challenging and also the way you organize your information when you receive it is really important. So I would suggest sbar. So like when you give a handover, you do sbar, if you're taking a handover, I would use SBAR. I, I've sometimes done it on um my nights and stuff where I've actually printed out templates and have SBAR or let's just say basic details to organize the information. Um So when I say I would make a table and we're gonna see that as an example in the station, um there's a, there's like a template I've made um where you have your patient list and you have your sbar and you fill in the relevant sections. Um And you always have your early warning score Incorporated, you always have on examination Incorporated Diagnosis Incorporated. Um We'll, we'll, we'll, I'll show you the example. Write in short form, do not, do not write in pros and make your life harder, try and find as many abbreviations and shorthand ways of writing information down. Um So for example, ews is quick, O slash E is quick, diagnosis is quick, just keep it short. Um And as I said, tailor questions to the scenario. So you always ask how you examined them. What's their score, blah, blah, blah. But then you have to ask something about, but have you done this for this presentation? You need to be more relevant to the scenario, but that's the challenge because it's a time pressure thing and you have to think as they're speaking. Um and then do not hesitate to ask questions. Um and also do not just think that they'll voluntary voluntarily give you all the information you have to probe them. Sometimes, sometimes they'll give you a rubbish handover, which happens in real life, you get really rubbish handovers. So, uh, just treat it that way that I haven't got all the information I need and I'm gonna, I'm gonna question. OK. Um, it shows your thinking. So that's handover. Um, and then moving on to prioritization, um, take your time. Don't rush, you're gonna get presented the results. So when you've got the two minute reading time, um you know, for this station following on, you'll get, I can't remember, but I think we had laminated sheets for all the results for each patient. So take your time and look at those results and just try and come up with a potential working diagnosis because only then will that determine how worried you are and who you want to prioritize? So the results really should help you be like, OK, I think this is, this is what's going on. Um So take your time with that and when you're uh explaining your reasoning to the examiner, um always begin with your most sick patients. It says that in the Mark scheme, it might be sounding like I'm stating the obvious but start with your most unwell patients. Um and explain why because while they're scoring for this, this, this, you know, this is their presenting complaint. I think this is that I almost present it like an sbar again. I think this is what they have because of this, this, this, this is what's done, this is what they've done so far, but they haven't done this. So I'm going to do this and I'm going to delegate this. Just, just have that going on in your head. It will make you follow through with your reasoning. Um I've put specifically what has not been uh done. It's five patients. Uh Lucy, five patients, if, if I'm correct, I've prepared five patients. It's been such a while since I did the station. But yeah, five. So the other aspect is what hasn't been done. So when I say this, I mean, um when you're, when you're asking them questions, have you done this? Let's say they say no note that down because ultimately, that's what, that's what's going to come of use to you when you decide to prioritize and delegate because then you'll know, well, this hasn't been done. Do I need to do so? Can someone else do this and then, you know, um the stuff that has been done that's fine. It'll come up in the investigation results, things that have been requested that will come in your results anyway, but the stuff that hasn't been done, you need to make a note of that. Um So that's something I'd I'd emphasize um as I said, present like an sbar when you're explaining your, your clinical reasoning. Um And remember your team, please. Oh my God. You know, the, the temptation to just be like, I'm the only one here and I have to do everything by myself. That is not the case. It tells you that you have what two A, one A NP and two H CS and a nurse, please use them. Um And yeah, delegate accordingly. Again, it will show your resource management, it will show your ability to work in the team. Um It's what happens in real life. You have tons of helping hands more than you realize. So you should be doing things by yourself. Um OK, those are top tips. I know this is a lot of, a lot of tips, but it'll only become relevant when we have an example. Uh Anything unclear so far. If not, then I will move on any questions, feel free to put them on. I'll, I'll carry on. So if you can see this. So this is an example of a template that I would personally use just because it'll make your life easier. So as I was saying, patients on one side and then your sbar at the top um and you fill in each bit whenever it's relevant. So someone starts presenting to you, this is patient X name, age, blah, blah, date of birth, whatever. So always as as I said, use shorthand form. So when you're writing, you don't even need to do patient one, you can just do 12345 and then you just have the initials because the name at the end of the day, it is not, you know, you, you just have the initials, that's good enough the age just to give you a sense of which age group you're dealing with. Um diagnosis is something you will perhaps fill in when you're more confident as you get the results. Um So do you need to ask date of birth and hospital number for each patient? Uh Yeah, I think for, I think for like as you know, even in real life, it's always important to have the full details for practical reasons, obviously, to search up the patient to make sure you have the right patient. So it would only look professional if you, if you ask that question. So they might just say we've got ex person who's a 90 year old, whatever. Um or they might just say the date of birth. But if they don't, then by all means, make sure you have your three identity details anyway, it just looks professional. Um Yeah, so note those things down and then, and then put the presenting complaint, let's say in situations. So for example, what you have presenting complaints. So you've got chest pain, shortness of breath, hematuria, blah, blah, blah abdo pain, put that as your key presenting complaint. Um but don't go on to write pros about, oh, this is what's happened. Just make note of some key things. OK? Uh And then background, they might tell you the past medical history, they might not. So make sure to probe, um, assessment always put your WS in on examination. So you can fill in the number and any examination that's been done. And then in recommendation, you can just write what's not been done, as I was saying before. So you asked about this, they haven't done this or you note down what has been done, um and so on and so forth. So da da da da, do you know which jobs different members of your team will be capable of doing or do you just reasonably assume? Yeah, good question. That's really important to know. Um So I can explain this now, to be honest. Uh But with the team, your, your AP is, is the PS are really good. They're, you know, they're like um us, they can assess, they can diagnose, they can manage, they can prescribe. Um So use your AP as if it's, it's another doctor, I would say just remember that your A ps, like another doctor, they can go and assess somebody very confidently and, and diagnose and manage and do skills and prescribe. Um So I would say, yeah, that HDs clinical skills, nurse, clinical skills, you know, if you need, if there's lots of clinical skills that need doing, use them, they probably have more experience than you, especially as an F one. It's weird how they give you skills to do what they've tried, but actually they've got way more experience. So use them for clinical skills. Um As much as you can. Uh The only thing I would say is maybe something like a blood gas, like an ABG arterial blood gas is as far as the only doctors can do. Um But otherwise most other basic skills can be done by nurses and H CS. So just remember that your A NP is like a doc is basically a doctor Um in terms of, you know, what they can do in terms of assessment and then your HC A nurse for clinical skills. Uh um What else have we got? Do you interrupt the person giving handover? I'd say let them complete, let them complete. Um I think when they say the first patient stuff like this is what they came in, this is their background and you know, blah, blah, blah, once they've done that, I think, then start with your probing questions. But it, it really depends. I mean, you could, I can't remember how I did it. Sometimes you just let them present each patient to you and then whatever time you have left, you use that to probe as much as you want. Um I think that's probably what I did actually, I think I let them present the basics of each patient and then I was like, OK, starting with patient one. Have they had this done, have they had that done blah, blah, blah? I don't think I interrupted too much at the start. Um Just go with the flow, but I would probably say let them just give you the basic information so that you know, roughly what's going on. Um Fine. So yeah, so that's the table for you. Now again, by no means do you have to use this, by the way, you can create whatever format you want, whatever abbreviations you want, but use a format that makes your life easier. Um That has information already there that you just need to fill in like just keep keep life as simple as possible. Um OK. Do you have any more questions so far? These are good questions. So feel free to ask away because we will you gonna go on to do a station now? So feel free. No. OK. Fine. So station time, right? So what we're gonna do is uh the way I was thinking of doing this is to have a volunteer, but I think this is a lot of pressure for someone to have to ask all the right questions in time. Um So me and me had a chat about that. So I think what we're gonna do instead is I am going to pretend to be the examiner. I'll set a rough timer in the background. I will uh give you guys maybe two minutes, let's say reading time uh in which you can make whatever table you want to read the brief. Um And then I'll start the 10 minute timer and I'll start presenting to you like I would in the exam. So probably I'll go through the patients. Um, and then the time that we'll have left in the 10 minutes in the chat, uh, try and ask specific questions and I'll answer them as we go along. Um, we've got 10 minutes so bear that in mind. Um, so there's any certain number of questions that you'll be able to ask because of the time limit, but we'll do it that way. I think it might be better than just having one person having the whole burden of doing it right in the first go. Um, that's what we do for this handover station. Then again, you'll get two minutes reading time to kind of, you know, take what information I've given you. Um, and then I will show you the results for any investigations and things that have happened, um, in the time again, setting, starting a 10 minute timer. Uh, and then once we have that we could have a volunteer at that point who just talks me through their reasoning as to who they'd prioritize and why if we don't have any volunteer at that point? That's fine. Then I might just ask you guys like, you know, guys who you're gonna see first and so on, so forth. So we'll just, we'll just see how it goes, but for the first station, at least there will be no volunteer. It'll just be chat like interaction in the chat. Hopefully that's clear. If not. Um again, feel free to ask. Um, but if we are ready uh and give me like thumbs up, you know, when the waving thumbs up or whatever, if you're happy with this plan, um, and I'll be ready to start a two minute timer. Ok? I can see. 123 cool, cool, cool, cool people are happy. Nice. Ok. So just to make it clear, I'm gonna give a two-minute timer. I'm gonna give you the briefing for the handover station station 15, read the briefing, make whatever table you want to help life to help make life easier and then I'll start the 10 minutes and I'll start presenting the patients to you. Does that sound good? Uh OK. Two minute time. All right, fine. So I'm gonna switch to the briefing start. I'm gonna start two minutes now guys. OK? Have a read and make your table or whatever. OK? That's time guys for reading. Hopefully you had time to prepare your table or whatever it is. So I'm going to start 10 minutes. Uh again, no one's volunteering. I'm just going to present you the five patients. So note down as much as you can in your table and then um and then after that, I'll open it to the chat to we'll take patient by patient and we'll ask a certain number of questions and I'll move on quite swiftly because we'll have a timer going um sound. Ok guys again I'm gonna just keep checking in so that no one feels lost in what we're doing. Yes. Lovely good, good good. Ok, so I'm gonna start 10 minutes and I'm gonna get my what I'm presenting to you ready? Ok cool. Thank you. OK. All right ready guys. So starting 10 minutes now. So hi I'm Anita. I'm one of the ones I'm just handing over to you for the AM U shift. Um Got five patients to present to you for handover if that's ok. So first patient, uh we've got Mister Sam Smith, 58 year old male and he's come in because he's got sudden onset uh 10 on 10 tearing uh central chest pain um or we've got hands up. I don't know why. Sounds good. Ok. Uh Central uh chest pain. Uh we, he was just lifting some heavy boxes. Um It's not improving with pain relief and he's also feeling quite nauseous. Um He's got sciatica and high BP. Um and uh his news at the moment is zero. Um And we've done an ECG for him which is normal. Ok. So we've got the second patient, uh 71 year old male, Mister Ryan Johnson. Um So he's a nursing home resident. He's actually come in because he desaturated in the nursing home. He became suddenly short of breath, they checked his satin, it was 88. Um He's hypertensive and he's a type two diabetic as well and he's got heart failure. Um, his news is six right now. Um, yeah, moving on to patient three. We've got a 38 year old female, uh, Sandra Smith. Uh, so she's come in with, um, sudden onset 10 on 10 generalized abdominal pain. Uh, she had a colonoscopy done yesterday to investigate Crohn's. She's got quite in serious severe Crohn's apparently. Um, she's feeling very, very sick. She's not vomited yet. Uh So Crohn's in terms of his uh medical history and she suffers from migraines as well. Uh Her news is 10 right now. Um uh Yeah, so she's, she's quite unwell. Uh So we've got the fourth patient, 84 year old male. Um, his name is uh Steve Smith. So he is, um, he's admitted with delirium at the moment. Um We don't know why but uh he went to the toilet in the middle of the night and he had a fall uh whilst going to the toilet. So he's hypertensive. He's known uh Alzheimer's dementia. He's got COPD and AF as well. Um, and he's currently a news of six. Ok. Final patient number five. So we've got a 47 year old female, uh, Missus Lola Andrews. Uh So she's come in with sudden onset low inter groin nine on 10 pain. Uh She's tried pain relief, paracetamol, but it's just, it's not, it's not taking the edge off the pain. Um, she hasn't got any relevant history. Um Her news is two at the moment. Ok? So now I'm gonna open it up to the chat and we're gonna go patient by patient and I'm gonna keep the time ticking as well. So first patient, what questions would you guys like to ask me? I'm happy to answer as much as I can and no pressure. Just have a think if you can't think of anything, no problem. What else has been done for him? OK. What, what do you want? What else do you want done for him? So what? OK. So we've got a specific question coming up. OK. Lovely, lovely. So fine. Um So bloods, bloods have been requested. We have done the troponin. Uh We're just waiting for that. He has been examined. I can tell you the examination findings. So uh his cardiorespiratory examination is normal. Um just that his left radial pulse was weaker compared to the other side. Otherwise, uh any other examinations, if you're looking for, feel free to ask, if not, that's fine. Uh surgery wise. Uh No surgical history. Um And we haven't given aspirin yet. OK. And BP, good question. It's 1 81/90 at the moment. Uh in terms of angiogram. No, we've not, we've not, no, we've not done aortograms, angiograms. No, not done any of that fine BP in both arms. OK? Uh There is a difference in the systolic blood pressures. Um It was 180 in the other arm it was 160 and has any low BP medication. No, we've not given him any antihypertensives yet. Yeah. So in the news chart, apparently 181 doesn't score, um, correct me if I'm wrong, but I think I checked this surprisingly. So don't always rely on news guys. Um, yeah, not given any hand here. So let's move on to the next one. I think we've had a good number of questions for this one. second patient. What do we wanna ask guys? Fire away. You're doing really, really well. Has a chest X ray been done? It has been. Yes, it has been. Yeah. Uh So what are they scoring for? Lovely, good question. So they need a six. So at the moment, they require 15 L of oxygen uh sats 95. Otherwise they're scoring for confusion as well. Um And yeah, and their respirate is on the higher side 19. Um What other questions have we got? Uh respiratory exam? Yes. Yes. They have been examined. They've got crackles bilaterally. Um And also they edematous both in the legs and sacral edema as well and their JVP is raised um Fine ABG has not been done. No, we've not done an ABG uh sepsis screen has not been done. Um Just bloods have been ordered for this patient. Have they been getting anything for the shortness of breath? Uh Just the oxygen, just the oxygen. They have not been given diuretics. No, no lactate levels. Well, we've not done an ABG yet, so we don't know. Yeah. A Curb 65 has not been done. No, no. And any chest X ray. We've uh yeah, we've, we've requested that he's had a chest X ray. Yeah. Ok. So we move on to the next patient. We've not actually got much time. But anyway, I'm not gonna pressure you. Let's just move on to the third patient. Um Good, good questions coming in. What do we wanna ask about this 38 year old female HCG done? Uh She has, yes, she's had a urine dip. Yes. And that was negative. What are they scoring for? Lovely. So she's uh nasal cannula right now. 4 L. Her SATS are 94. Uh She's tachy N 20 I mean, on the end, uh she's tacky uh 110 and she's hypotensive 91/58. So she's hemodynamically unstable and she's also got a temperature. So she's scoring for quite a few things. Um ABDO exam, she's not been examined yet. She's very, very rigid right now. She's just not moving. Um Is there an Abdo x-ray? No, we've not done an ABDO x-ray for her. No uh sepsis screen done. Um sepsis screen. What are we looking for exactly for sepsis screen? Uh What do you want? And surgical team plan and escalation plan we can discuss that. Has she had fluids? Uh No, she's not had fluids yet. She's not, had fluids still needs prescribing. Um, okey dokey Buffalo. What is Buffalo? Anyway? I don't know that one antibiotic started. No. No. Yeah, she's got a candy in, she has got a candy in and a sepsis screen. If any further thoughts. Then please ask. So. Yeah, we've got bloods, urine fluids, antibiotics, lactate oxygen. Cool. So, she's had a VBG. Uh, she's had a VBG. Um, other than that she's had bloods requested. Yes. Yes. She's had cultures. Yeah, she's had her cultures. That's right. Yeah. Just fluids and antibiotics. We've not done any of that. OK. Right. So let's move on to the fourth patient. OK. We're not doing too badly. Fourth patient. What do we want to ask about an 84 year old male examination? What examination do you want? What examination? Ok. So what are they scoring for? So he is scoring for confusion. He's scoring for confusion. Um bla bla bla I'm trying to remember what else. I think it's mainly for his confusion. Otherwise he's hemodynamically stable um at the moment. Yeah. Uh Oh wow. Quite a few questions. Lovely. So uh bah bah bah OK, examinations will go on with. So uh he's not been examined. No, he's not been examined. He had the fall in the middle of the night. We still need to not middle of the night. But uh let's say the day I can't remember the history but he's not been examined at all no abdomen, urine, nothing, um, head injury or other injuries from the fall. Ok. The fall was witnessed, it was witnessed the nurse was trying to assist him and he lost consciousness. She said he didn't hit his head. Um, in terms of risk to himself or others, he's got a background of dementia. I'm not sure about the risk assessment. I haven't really looked into the history. Uh CT has not been requested. No. Uh, we've not done a lying standing either. No, we haven't. Does he have a catheter? Uh, let's say no, he doesn't have a catheter. And are they on any medications? They're quite on a bunch of antihypertensives. He's on an inhaler for COPD and anticoagulation for his AF and just his Alzheimer's medications. Uh, falls bundle. No, no, nothing. And ECG ECG, has it been done? Let me check for you. Uh, ok. That is actually time. Uh, let's say E CG hasn't been done, um, on blood thinners. Yes, he is on blood thinners for his af That's right. Any bloods done his bloods, uh, have. Mhm. They have been requested. Yeah, he's had bloods done but specifically. No, no. Ok. So that is time. But again, this is more about principles. So we're doing so well. Let's just do the final patient. Really, really good questions guys. Honestly. Um, final patient, what do we want to ask about this? 47 year old female? So urine dip, um, urine dip hasn't been done yet. It was positive for hematuria. Yes. Uh What else did you ask? HCG uh no um negative for HCG. Um What is she using for? So she's using for her heart rate. She's slightly tachy 101 and she's got a temperature 38.2 right now. That's what she's scoring for. Has a CT KUB been requested. It has. Yes, it has. Um any other pain relief given? Nope, no, she's not been prescribed any pain relief. Actually, just the paracetamol which is not helping. Um Yes, so except paracetamol, nothing abdo exam. She has been examined. She's got slight uh slight renal angle, tenderness, but otherwise uh nothing extraordinary. Uh Let's have a look. So use these. Yeah, so her bloods have been requested. Yes. When did she last have paracetamol, let's say an hour back. It's just not helping. She's tried and it's just not helping take the pain off any further questions, guys has urology. No, we've not actually discussed with urology yet. Um We sent off the CT but no, not discussed with urology yet. Uh Fluids. Uh No, no fluids, a sepsis screen hasn't been done. No, hasn't been done. No. Ok. I think uh we'll probably call that time honestly guys really, really good questions. This is really, really good. Um I think you've picked up really well. So that's essentially the handover part. Ok. Um And now what we're gonna do is I'll give you further two minutes to have a think, just assignment, like, bring together all your thoughts as to what's going on so far and then we'll go on to prioritization. Uh, just, uh, before we do that, does anyone want to volunteer to explain their reasoning? Or, uh, if, if you do then volunteer now, I'll maybe give it a couple of seconds and if not, then we'll again, do what we did. Go through the same drill. Have the chat for interaction again. No pressure guys. This is a scary thing to do. No. Yeah, I think the chat thing worked well. Anyway, fine. Ok, so I'm gonna give two minutes guys again for you to just collect your thoughts. Then what we're gonna do is we'll do 10 minutes where I'll just ask some questions as to you know how we should go about this. Fine. OK. So happy to move ahead guys. Yeah. All all. Ok. Send me those thumbs up flying thumbs ups. Yeah. Good. Lovely, lovely. OK. I'm gonna start the two-minute timer now and I'm gonna switch to the next briefing. OK. Starting. Ok. So that's two minutes up. Oh someone said I'll try. Do you still wanna try Isma? Would you like to volunteer? Oh OK. Nice. Lovely. Very brave. OK, cool. So uh what we'll do then is I will start the 10 minutes and I'll show you all the results, all the investigation results. I think this is how it happened in the in the real thing. Yeah, I remember faffing about with those of papers. So, um, yeah, just have a look at the investigations. Then when you're ready, um, start talking me through your clinical reasoning, um, who you want to prioritize and why. Um, and then we'll, we'll take it from there. Does that sound ok as well? Um, yes, it does. My camera doesn't work. So, is it ok if I just, um, my, Yeah, yeah, just use your mic. No problem. Um Just da da da da da uh for the rest of you as well. So firstly, really good for is for trying and for volunteering. That's awesome. Um And for the rest of you um just feel free to again think and what you would, you know, do in terms of prioritization. Um And if there's anything else that you want to add, you know, um perhaps feel free to suggest towards the end, but we let a volunteer. Um So fine. I'm gonna start the 10 minutes a smile. OK? And I'm gonna show you the investigation results and then whenever you're ready to start talking, let me know. Yeah, and I'll unmute. Sure, cool. All right. So showing you guys the results now. Um Here you are and I'm starting 10 minutes now. Oh, that's a very good point. I paused a timer, by the way, guys references, feel free to actually pull up if you want just a page on Google of the reference ranges just to help you with the results, they should give you reference ranges. Yes. Thank you for reminding me. Yeah, just feel free to pull it up and have it in front of you so that you can see what's abnormal. Yeah, thank you, Ria for pointing that out. Yeah, I'll start the timer. Um, just let me know guys when you've pulled up ranges, then I'll start the timer because it's not fair for you to be faffing about. Has everyone had a chance to pull up a just a reference range for bloods. Got them up. Yeah. Yeah. All good. Just get a few thumbs up and then I'll continue the timer. Yeah. Yeah. Got another thumbs up. Cool. All right, I'm gonna resume the time you guys. OK? Um Hi Nikita. I'm ready to, I'm ready when you are. Perfect. Yeah, go ahead. Uh So the examiner will probably say to you. So go ahead, explain your clinical reasoning. So, yeah, go for it. Um Hello. So um based on the handover, uh I have five patients which I'd like to prioritize. Um the patient I believe that needs to be seen most urgently is patient three, the 38 year old female who is scoring gay 10 out of 10 is scoring gay 10 for news. Um and on, on the background of her recent uh surgery for her colonoscopy, her colonoscopy yesterday for Crohn's, I believe that she might have a perforation and this is consistent with the investigation findings of a pneumoperitoneum. Um I believe that because she's hemodynamically and stable, she needs to uh urgent fluid resuscitation, um antibiotics as well. I'd like to start a 1000 mL uh bolus of uh IV saline over 15 minutes if that's OK. Uh 505 100 m over 15 minutes. The next patient um I'd like to talk about is patient number. Um Patient number two, I believe, um who is a 71 year old, uh 71 year old male, um who presented with um uh presented with symptoms of heart failure. I believe that I believe uh based on uh the, the chest X ray and the um and the investigation findings of uh BS is consistent with my diagnosis. I would like to order um some uh I'd like to give this patient some uh some medication um potentially a loop diuretic to um to remove some of the excess fluid in their body. Um And uh review, review the medication and moving forward. I think the next patient I'd like to pay attention to is patient number. Uh Patient number one, the 58 year old female who's presented with a sudden onset chest pain. Uh The reason being is because despite the normal uh ecg um the troponin is raised um above the threshold for a female and uh for a uh for a, oh, I'm not sure. Oh, ok. For a male Um uh And because um because uh intervention for uh MS have a strict window of um have a strict window for time. I II feel like this patient needs to be seen quite urgently if any further investigation or intervention needs to be done. Um The penultimate patient I'd like to prioritize is um the 84 year old male. Um patient number four, who presented delirium um and who had a four going, I was going to the toilet a me based on the uh investigation findings. Uh I see that they are uh just uh I see that they have uh what appears to be um a pneumothorax, potentially a pneumothorax. Um And um which could, you know, which could be uh a cause of full, I'd like to further investigate, further, investigate this um by seeing uh by doing a full, a full bundle and check, reviewing that medication as well. Um And yeah, the, an, the antihyper i antihypertensive that they're taking. Um I'd want to also do an ECG because they've got um a um and just checking if they're going through if they have symptoms. Are they at the minute? Um I'd want to do a few, uh I'd want to do a neurological examination on this patient just to see if they've suffered any, um any uh intracranial hemorrhage or anything like that as well. Um I believe my final patient now is uh the patient number 5, 47 year old female who is presenting low to grow in pain, uh, which is a sudden onset in nature. Um, she's going in use of two and because she's tachycardic and I believe that this patient could be, uh, this patient has, uh what appears to be a kidney stone which can be treated, um, with, um, with medications such as, uh, uh I diclofenac, diclofenac for pain relief. Uh, whilst we uh investigate, um, further intervention, uh because of the size it is likely to pass naturally. Um So I think we might just keep her for observation though. Um Yeah, I'm not, yeah, I think I'm not happy. No, well done. Firstly, well done. Ok, I just have a few more questions for you if that's OK. We've got some time left. So uh firstly, just uh tell me you. So you're most worried about um patient three you said, right? Um So yeah, fine. Uh just to clarify. So for each patient, just tell me the working diagnosis you have in mind. So patient three, you told me perforation and then just tell me next in terms of your priority list of what you're thinking. Uh perforation for number three, number two, heart failure. Number one. am I uh before a me? Uh I number four, I think it could be syncope. Uh But II I'd have to exclude it. And then number five, just a, an a renal stent nephrolithiasis. Ok, lovely. And uh you explained to me your priority list as to who you think is most unwell. Just explain to me practically how are you going to sure go about seeing them and how are you using your team? Sure. So, um I'd like to uh delegate some tasks. Um I think for the patient with you, I need to contact the surgeons as soon as possible, um potentially make a referral to get her into theater again. Um and try to see if there has been a perforation. Um I want to also speak to the radiologist to arrange a um an abdomen, uh a ct of her abdomen. Um Patient number two, I'd want to speak to the cardiologist or whoever the med uncle is. Um and just see if they can chase up um uh chase up her, chase up the um loop diuretic which would help her symptoms, uh help their symptoms. Sorry. Um Number one, sorry, number two, I uh number two would be the dose we spoke for your doctors uh and cardiologist. Oh, sorry, a cardiologist under the heart failure. And likewise for patient. Number one. Number four, I believe that I want to contact the neurologists um to review this patient since they've had a fall and I'd want them to do AAA neurological examination. And number five, I'd want to refer to the urologist. Um Yeah. And uh what about your, your nurses, a NPS on your ward? How are you how are you making use of them? Um um I uh so for patient, the, my most uh the, my patient who needs to be seen most urgently, I'd want my nurses to, I, I'll, I'll prescribe the fluids and the uh and the uh antibiotics, but I, I'd like my nurses to uh administrate, administer it to the patient and check if they need a cannula or anything. Uh Likewise with um uh likewise with the other patients, if they needed any investigation, if they needed any cannulas or anything or any. Uh and uh I think, don't worry, take your time. Mm Yeah. Um I guess for patient number four, I could get uh an A MP to do a false history um and speak to speak to the witness who attended the fall as well. Um And for patient number one, that's fine as well. That's time you can breathe now. OK. Leslie, can we, can we please give him like a like a clap because II thought you were amazing. You're really, really, really good as well. You had such good line of thinking and, and thoughts. So firstly, well done. Big, big, big, well done. I would have never attempted this as a as a final year. So big clap, lots of applauses. Um Yeah, I mean, I II think that was very well done. You had so many good ideas. Um I think of course that we can go through feedback and, and maybe an example of, of how to go about this, but you definitely had some good line of thinking, uh for sure, for sure. Uh How did you feel Asma was? How did you think that went? Um You did really well, you did really, really well. Um OK, so uh maybe let's go through this is the, the specific positives. Um I think you recognized who's unwell. So even actually if we go back to the Mark scheme, uh I don't know if uh uh let's see. Ok. Yeah, let's go to the Mark Scheme then. So uh yeah, so I think um you, you definitely recognize who's unwell and you definitely recognized what things need doing what specific tasks that demonstrated your knowledge. I think your strengths were that you, you, you know your clinical conditions. Um And yeah, you were, you're good at picking up who, who needs to be seen. So I think that departments is, is, is great. Um And your reasoning as well was, was good for, for the most part, I think um management as well. Yes. And then in terms of reviewing, I think probably the part if we go on to maybe the, the things that need working on is how you're using your team. And practically speaking, when you're physically there in the hospital, where are you going? Who are you seeing? Who are you sending, where um what are they doing? I think that perhaps we, we can talk through a bit more um in terms of delegation. Um But I think your knowledge is absolutely there. I have no concerns with, with, with knowledge. Um So that's just just, you know, general feedback for, for your smile for the station. Um We can go through sort of diagnosis and by all means, what I'm gonna show you is probably not got everything. I think you guys have suggested things that I haven't thought of. So I think this is, I think you've all done fantastically. Well, uh we can go through sort of an example answer. Um just in terms of uh to answer this question on the chart before we go through the um do they give you a table like this in the exam? No. So I think it's a lot of sheets. I think it's a lot of sheets. It's not like a compact table. So uh yeah, just to warn you uh be prepared for, for, for documents to, to be given to you. I don't know why I felt like in the exam, I had a table but it's, it's honestly a blur to me. Um I, yeah, but I'd say be prepared for, for the worst. So it could be am multiple sheets that you have to kind of read through. Um Is there only one right answer? Good question. No, no, there, there, there's, there's multiple ways of going about a scenario and I'm sure that the case is the case that they might give, you might have, you know, multiple ways and in real life, that's how it is. Guys, you're not just, there's not one set template for how you manage the clinical situations. I mean, there is always ways you can optimize it. But I think for the exam purposes, as long as it's sound reasoning and as long as you're recognizing who's sick and you're not prioritizing a job that could actually happen later over someone who needs something done. Now, that's what they're looking for. And then, you know, who you use and how you use them, that can be that can, that can vary. But don't, don't put non urgent jobs above sick patients. It's, you know, ultimately, I think with any station medicine in general it doesn't, even if you're not the most knowledgeable, um it's about being safe. So always prioritize your sick patients. I think that's the key thing with this, with the station and why you think they're the most sick. Um Will we need to interpret imaging? I don't think so. I don't think they gave proper images. I don't think so. I wish I had these answers for and I wish I remembered why. What, what happened exactly. But I don't think there's, there's images that will be too much. Um But I can always check with uh with someone else who's done this and get back to you in some way. Um But yeah, you, you might have sheets and imaging. So yeah, no one way to do this guys. This is just a suggestion. So what we're gonna do is I'll take you through an example of the table that I would have for the handover. Then a table for, let's say additional details. I add when I'm trying to listen to the handover, blah, blah, blah, and things that haven't been done. And then I'll give you an example of where would I go? Who would I see? Who would I delegate to blah blah, blah? OK. So I mean, you can see this. So this is the table I'd go for. So I haven't filled diagnosis as you know, at that point necessarily. Um but the things in red are the additional things that I would note down. So first patient, let's go through that. So uh in terms of history, actually, in the chat, there weren't many questions about the history. Um We most of the time actually went straight to assessment and what's been done, what's not been done. Um So do ask more probing questions about the history itself. Uh Don't forget that. Um So for example, the first patient, um so I've said uh central chest pain radiating to the back. Um And then to the assessment, we asked about BP, very good. So no one just thought news is zero, we still checked BP. Um and also difference in BP is very, very good question because we're thinking dissection specifically, I know small you were mentioning m um but with the history, central tearing chest pain, um we're thinking along the lines of dissection as well. That needs to be also the top mi obviously is a very acute presentation. You have to remember that. But dissection specifically as well, um we should keep in mind and then examination good. We asked about that. We specifically said cardio exam um just in terms of overall thinking back pain whilst moving or lifting something, think MSK think neurological just just in case. Um but all those examinations are normal anyway. And then bloods, we said we requested good thoughts about CT angiogram. Have we ordered that? Have we not ordered that? Ecg I told you about, so we were all thinking along the right lines. I think we had dissection at the forefront definitely, which is good. Second patient. Uh Let's have any questions by the way, so far about patient one, I feel like I'm just blabbered. No, OK. I'm gonna assume no patient two, right? Uh acute shortness of breath. Uh So again, uh bit more but from the history maybe. Uh so I don't think anyone asked me about chest pain, leg swellings, coughs. I don't think we had any symptoms or questions. So history just make sure. So acute shortness of breath. Again, this is about presenting complaints. Guys, I always think for final year just go through presenting complaints. So what key questions would ask about chest pain. What key questions would ask about shortness of breath? So I always divide shortness of breath into acute and chronic. Is it, has this been always happening or is it actually suddenly out of the blue? Because if it's suddenly out of the blue, then you start thinking about your acute causes. So, can we just come up with some acute pauses for shortness of breath quickly in the chat? 71 year old male. Keep that in mind. Yeah. Pee. Yep. Yep. Yep, yep. Asthma. Yeah. Yeah. What else? Pneumothorax? Good. I think you were thinking that a small pneumothorax, co PD. Ok. Yeah. So what specifically about CO PD? Um What are we thinking? Uh, pneumonia? Yeah. Good. Heart failure. Good. Good exacerbation. Lovely, lovely, nice, nice, nice, very good. Very good. Yeah. Keep that in your mind. Ok. And then you'll ask questions accordingly, right? So you'll ask, are they a smoker? Um Have they got chest pain? Have they got leg swellings? Have they had difficulty sleeping at night? Are they breathless? Um Have they got calf pain, uh you know, recent travel history, surgical history, immobile, blah, blah, blah, blah. Um All of those questions. So yeah, more in this, in the history. Um So it depends, I think you in terms of taking up lots of time. It's definitely a good question. I think you have to just be very blunt and just ask your key questions. So if you're doing acute shortness of breath. It's important to ask about chest pain. It's important to ask about your pe stuff. It's important to ask about, you know, other risk factors. But obviously you don't want to do an, an elaborate history, but these are very quick questions. So I think my tip would be even if you have presenting complaints, um you just have your red flag questions. So for chest pain, you need to ask, you know, radiation and whatever um palpitations, syncope every history or presenting it has red flag questions. So I would recommend that for final year. Um OK. Yeah, but yeah, don't take too much time. So good point. Fine. OK. So for background, yeah, I mentioned background uh da da, da da um I mean something to ask if they've had PS and DVTs before. Um but you know, um news again what they're scoring for, I think for news, another tip is if their BP and heart rate is fine, just write hemodynamically stable hs you know, you don't need to, you know, intricately write every number. Um And then in terms of recommendations. So chest X ray, we asked about ABG, I think we asked about very good bloods um on admission. Yes, that we requested, but no BNP actually, I don't know if I said that or not, but anyway, you had the result for that. Um So we're thinking along the lines of what working diagnosis are we thinking? Of, I think it's small. You said heart failure. But what are we specifically saying about heart failure or if someone has anything else in their mind for the diagnosis? Yeah. Decompensation. Yeah. Yeah. AQ heart failure. Nice. Yeah. Yeah, exactly. Acute sort of heart failure, exacerbation. Yeah. Pulmonary edema. Good. Yeah, that's what we're thinking about. Lovely. And if you're actually quite confident already by this point, even without the results, you can always put it as a thought in your diagnosis part. You know that this is what I'm thinking. Fine. OK. Let's move on to the next patient. So patient three. so um just with abdo pain, always ask about bowels, always ask about bowels, have they opened or not. Um And then uh yes, history I told you what they're scoring for. Again, hemodynamically unstable, just write that if they're tachy and hypotensive. Um and they're scoring for other things. Examination you guys asked me about very good. They've not been examined and then there's a ton of stuff that hasn't been done for this patient. OK. So again, note that down, OK? This is not done, this is not done, this is not done so on so forth. OK. Fine. Um As far as you said, perforation, everyone in agreement, we roughly thinking perforation for this patient. Yeah, I think so unless anyone disagrees fine. Uh This is an actual case I saw uh this is a real life patient. Uh Very unfortunate but Yes. OK. Patient four. So again, similar thing. Now, this is probably a good example for history guys. So I don't think anyone asked me about presyncopal stuff. So this is again to do with falls um falls syncope if there's a loss of consciousness. OK. Syncope, your causes for syncope. So cardiac um so always think about your basic things. Have they not got a high enough BP? Have they not got enough sugar in their body? Have they um have they got weakness on one side? Ok. Did they have a physical reason for falling? Was it just a trip over something? Um and then obviously witnessed head injury, those questions did come up, which is very, very important. So very good life deliberately didn't tell you witnessed and no unwitnessed. So very very good, but ask about seizures as well. Ok. Elderly people can be different. They don't necessarily have to present with tonic clonic. They can just have a loss of consciousness but ask about, you know, incontinence and tongue bites and blah. So do your falls, your falls history. But again, uh like it was asked before, don't take too much time. Um History was given scoring blah, blah, blah, um BMS. I'm not sure anyone asked me about, forgive me if I missed that. And examination wasn't done. I think for examinations, we ask questions about neuro um which is very good. Uh for elderly, I would always say do a full top to bottom chest, you know, abdo um all of that um with cardiac examination, why is that important for a syncope, syncope uh in an elderly person? Why is that important? What kinds of things would we be looking for? Yeah. Good valvular disease. Good arrhythmias. Yeah. So we're checking the pulse. Good. Yeah, postural hypotension. Exactly. So lying standing someone said, which is really important. Ecgs again, syncope always just do it, always do it. Um, and uh confusion screen is something to think about because that's what they came in long term. And medication review I think is small. You spoke about medication review as well, which is very, very good and the antihypertensive. So we, we're working with what's our working diagnosis roughly are we thinking, uh, for this person in terms of the fall, given the investigations that you guys made note of as well? What are we thinking is the cause of the fall? Any thoughts? Ok. So the most common things if, uh, lying standing BP, we said we noticed a difference. It could be a postural drop, it could be a postural drop that caused it. Ok. Um, that, that would probably be the top thing that you think of for this patient. The BMS are fine. Ok. So it's not a hypo, it's not a hypo. We still need to do obviously have the ECG medication overuse. Yeah, you would review your, your doses, any sort of, yeah, falls risk medications anticholinergics. Yeah, that will be part of your med review. Exactly. So there's still some information gathering to do, but given the history and the BP difference and they're on antihypertensive, you'd always keep that in mind. Yeah. But neuro exam is important. Cardiac exam is important. E CG is important. So, yeah, good. Final patient. So let's move on. Um for this patient uh again, uh sudden onset, low to groin, we had pilo and we had stones obviously as the diagnosis from the CT. But in terms of history, just ask you about urinary tract symptoms, ok. Um And things like hematuria bowels because again, yes, loin to groin is your cla loin to groin is your classic for parlor and kidney stones. But remember flank pain and things like that, always ask about bowels, um uh as your history. Um And then obviously, the spiking your temperature and then we asked about the investigations, urine dip and M CNS as well and bloods. Yeah, and CTK would be good. So we had all the, all the right thoughts. Um This is just an example table. The next one is sort of, I fill things in, in green. Obviously, you don't have different colors in the exam, but you just write down the things that you, you, you need doing. Again, I want to emphasize not the things that haven't been done because it determines how you're going to delegate. I cannot emphasize this enough. Um This is how, that's how real life works. Ok? Um It will direct your management. So I've put some rough ideas in green. So for the dissection, analgesia antihypertensives, you know, acute management, what are you going to do to provide relief to this patient? Um And let's say for the second patient. So I'm thinking, OK, a pulmonary edema pneumonia, I'm querying. Ok. Are we gonna give frusemide? Because we think they're overloaded, catheter as well. Very important. So anyone who's fluid overloaded, who's been offloaded, you need to do a catheter to monitor the output as well. I can see a hand raised. I don't know if that's been there for ages but feel free to pop in the chat if you have a question. Um Yeah, third patient. We're sort of working with Puff. Yeah. You know, exacerbation of their Crohn's. So for a puff again, it's very important. You do your septic screen. You get in contact with the surgeons. I didn't put that down. That's very important. So get in touch with the surgeons stabilize your patient with broad spectrum antibiotics. Um and then get that CTAB do vetted. Um but sometimes, you know, if it's very clear, it's a puff, you know, they go straight into theater. So, yes, patient four. we think have postural vasovagal as well when they go to the toilet. Very common because of the autonomic activity, they can, they can lose consciousness. So keep vasovagal in mind as well. Um And I've mentioned Lys Standing. Yeah. And then the fifth patient, we're thinking, yeah, renal colic stones, pyelonephritis. And we had the diagnosis in the CT. We mentioned diclofenac very important pr uh uh given rectally. Um And then your, this is taken over from urology. I think with this patient, the blood showed raised infection markers. So if you're developing a complication as a result of the stone, um then you would need some form of surgical intervention like a stent or whatever. Um But yeah, is that clear guys? I've, I have spoken a lot, I've just gone on and on. Any questions about that and then I'll talk more about the logistical side of things. This was just a what order would you have seen? Yes, I will, I will go through that. R don't worry. Um That's my next slide. Any questions about the handover or how to go about organizing your thoughts? Because this is something I really struggle with even now. Any any questions about that? No, I think everyone wants to know how we're gonna manage this logistically. OK. Fine. So this is just an example uh just in terms of tips. So most unwell patients do we need to mention senior review? Yeah, II would say so. Yeah. And again, which specific teams I think, smile again, you sort of said which doctors you're going to involve. Um But uh you can always say that once I do these things, then I'd get cardiology or the urologist involved or I'd get like, ism did, um, don't forget what you can do what's in your power. Um, so I think maybe a small, at one point you said about examination, I involve neurology. You can examine all basic examinations. You can do yourself. It's just when you need intervention, uh, after you've done everything you can in your power that then you involve the higher ups. Yeah. but basics your basics, what are you gonna do to stabilize the patient? That's, that's down to you. So, um yeah, so in terms of unwell patients, I'd say most unwell. Um I would say in terms of my absolute absolute priority is one and three. The dissection and the uh the puff because the dissection, I just want to get that CT autom, I want to stabilize their BP and they need to go into the theater. Um Depending on what the dissection is. If you remember type a type B, which one needs theater? Which one doesn't um that, that would be blinking in my mind. Dissection and perfect dissection and perfect as for the pulmonary edema. Yes, they are. Well, they do need diuretics but you know, I think the dissection and p need sorting out. So you want to sort out your most unwell patients. So even in your table guys or whatever you use, whether you put a star or your numbers for priority, um assign roles next to each patient. OK. So this is again, something perhaps it's more like use your team a bit more. Um So as I said at the start, actually, someone has a really good question is how do we know what each person can do? So what can an AP do? What can a nurse do? So NP is just like you, they can assess, they can, you know, prescribe, blah, blah, blah. So use them. Um So in this case, I would think of it that way that who can actually go and do an assessment and you know, prescribe and who who needs to just do a ton of skills. Um So nurses in H CS. So if you've got more than one unwell patient, just suppose and you're really stuck, I've got tons of unwell patients, then you go and see one, send your A NP and then any skills that you're doing, use your nurses in HC. So for example, patient one, I need to give them the pain relief and the stabilize their BP because I'm querying dissection. I need to get that CT angiogram requested and, and vetted and arranged. So I need to discuss that I can sort that out. Ok. My A and P can go and see patient three because they've not even been examined. Ok. I know they're not laying it, they're quite rigid, but they need to be fully assessed and an can do that so they can go and do that and then the clinical skills because I think what cultures needed doing. And um there was a couple of other things I think that needed doing for the patient. Um that all that can be done uh by the, by the nurse. Would you talk to surgery before waiting for CT and your results as well? Yeah, I think that's, that's a good point. So sometimes in, in clinical practice, they always recommend it, recommend giving the surgeons a heads up uh that this is what I'm potentially dealing with. Um And then obviously you, you get that scan sorted. Um But if there's no harm in giving them a heads up, they will always appreciate that. So that's a very, very good, very good thought. Um So yeah, I definitely get involved with them. Um Yeah, so NP she can go and see that unwell young femur with the puff clinical skills can be done by the nurse. Um As for patient two, still still the unwell. Um but you can only do the ABG. So once I've sorted my dissection patient out, I'll go and do this ABG just to assess what we're looking for in the ABG. Why am I doing an ABG for, for the pulmonary edema? What am I looking for? What is the point of the ABG? Yeah. Yeah, you're trying to look for respiratory failure. Yeah, exactly. Exactly. That's right. So you're looking at the oxygenation status, this will come become more familiar in clinical practice. But for this amount of oxygen, what level of oxygen am I expecting in the blood? And if I'm giving this amount, this is what I would hope. If it's not that, then this, this tells me how unwell this patient is. So you'll come across all these things like Pao two and two and all of that and what you'd expect, it'll give you a sense of how bad the oxygen oxygenation status is. But yeah, respiratory failure. Absolutely. So again, yeah, you do that. Um And you give the Freezy, ok, you offload them. If it's electronic, you can do everything remotely. Um but if it's like paper based blah, blah, blah, then you're running around. Um but that's not really relevant in the case of the OS, you just need to make sure that you do the ABG and prescribe the, the diuretics. Again, a catheter can be done by an HC. So any other skills that need doing the HC can do um then you've got your fourth patient which is the da da, da da the four. Yeah. So the four, they do need to be assessed at some point, but because they're clinically stable, they've had a long standing BP. Um and the ECG that can again be done by the HC and you can always, it's always closed loop. You say to the HC, please do this ECG please do this lying standing BP. If it's not been done and relay it back to me. Let me know once the ECG is done, I'll review it when I can always closed loop, closed loop. Ok. So, um that's why we do. I've not mentioned patient five. But again, that's just a urology discussion. You'd give diclofenac for pain relief, but otherwise they're clinically stable as of now and then antibiotics if you're thinking infection. But what I'm trying to get at is that one and three are, are at, they're blinking in my mind. I can't miss a dissection and I can't miss ap like I have to sort those two out. The pulmonary edema is offloading them. Yeah. And then everybody else, you know, if they're stable, they can be assessed later. Um And if you're still sorting out urgent jobs again, your A and P can go and do a FS assessment, blah, blah, blah. That's kind of my rationale. Um Again, what was the actual diagnosis for patient? Two, patient, two, patient two. Yeah, pulmonary edema. So, exacerbation of the heart failure, they're known heart failure, but perhaps the the diuretics they're on are not optimized. Um So follow up, you would need an echo for them eventually to redetermine their cardiac function. All of that if it's not been recent enough. Um But yeah, that's the diagnosis for the pulmonary, the pulmonary edema for patient two. That's my rationale. I'm gonna stop there and ask you guys if you have any thoughts or any more questions. This is a lot um and I'll kind of do a nice summary at the end um of the key things you need. That makes sense. Yeah. Good, good, good, good. Any more questions, guys? I feel like a frazzle. You. I hope I'm not frazzle you. This is a lot of info. So yeah. Ok. I'll So in what order would you prioritize? Yeah. So I'd probably keep, I'd go and I'd go and sort out patient one personally get the CT stuff sorted. I'd send my A and P to patient three. So I'm kind of putting one and three in the same category. It doesn't have to be like, 01 after the other. It can be two people you're worried about, right? And then you delegate. So then that splits the workload. So I'd keep one and three at the top of my mind. Then I'd keep the pulmonary edema patient too, I think uh the fall, I'd, I'd get the blood pressures and the ecgs and make sure there's nothing crazy like a really like a Brady or something, but they're stable. Um And then my kidney stones I'd not be so concerned about because it's, it's clear and they're not septic, they're not very obstructed. Um So yeah, they're all good. Ok. I'm glad. So I'm gonna do a very quick summary guys and then I'm gonna let you go because this is a, a long session. So, um can you call the patient's numbers or should you use their names? Um I'd say use their names, use their names. Yeah, like you know the patient one, even in the, when you get the results, they might have numbers, just see what information is given to you, but otherwise just refer to the patients by their names. Yeah, that should be fine. Um ok, so handover, handover is about information gathering, ask as many probing questions as you need to like you guys did um get all the information you need. Don't think they voluntarily give you everything. Um and have a very systematic way of noting down whether it's the table I use or whether it's something you've created. Mm just fill in blanks so that you just have to fill in blanks. OK? Make your life easier. Feel free to shorthand, use numbers to prioritize uh so on and so forth and write down what's not been done, what hasn't been done? OK. Um And then prioritization, this is about who is the most sick, please sort the sick people out first if there's too many sick people delegate uh according to the remit of the, you know, this A NP and then the others just do whatever measures you need to do in the interim and ask people to feed back to you but sort out the unwell patients first always because that's what you will regret. You can't get, you can't do an un no job and then come back to the sick person, that's what they're looking for. Um And as a and again, write down who you're delegating to. Oh A and P for this one HC for this one. Me for this one. and number if you want for priority. Uh and then if you get the chance you have some thinking space left summarize for, for the examiner, it will show clarity of thought. Um Yeah, I think that's it. Um Are we, are we happy guys? Was that? OK? I've got some positive comments. Good, good, good, good, good. Any more questions? No, no problem guys. Honestly, II really hope this helps you. And I just think you guys have, you've done so well. I'm so so impressed and I think I have no concerns uh knowledge wise. It's just about organizing yourself and how you use your team. Please use your team and treat the sick ones first. No problem, no problem. I hope that's helpful guys and I'm gonna stick around. Um Yes, your feedback. Yes, I forgot about that. And any questions please ask me now while you have me or if anybody, I don't know uh if should I give an, I'm happy to give an email, you know, if anybody wanted to get in touch for anything. Um No problem, no problem. Lots of familiar names, no problem. Feel free to ask any questions guys, I'm gonna stick around otherwise. Uh So the all the best guys, by the way because I won't see you guys, but all the best you're gonna do. So, well, all of you, all of you stick around.