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Hi, everyone. Um could someone just write in that they can hear me in the chat or on mute? Yeah, we can hear you. Perfect. Thank you. I'm gonna get started to let you like one minute past six cause quite a bit to get through. So I'll get this sorted here now in a minute. OK, fine. So if someone will tell me once I share this, will it share properly? What do we see? It's OK. So I'm sharing this now. Um Can someone tell me if they can see it as a powerpoint or if they see it with like the black boxes underneath? No, it's just your apartment. Perfect. Thank you so much. I'll give it to you like one max two minutes past, I'm going to get started. So there's quite a lot here and if any wifi issues or anything, um if I don't see them or this cuts out just right into the whatsapp Chat or right into the chat here and I'm just gonna get started here. So um my name is Nicole. I'm one of the final years just finished F zero and I'm gonna chat through AY today. Um So I have a bit of a disclaimer here before I begin. I'm just gonna check. That's fine. So this is my disclaimer before. Just to remind me to do it. I want to apologize that I've had to move this so many times with the musical and with, um, somebody else needed my slot on Sunday. So I moved it to the day of the musical, but it's all sorted now. And I also wanted to just clarify that there is some slides in this that I'm not going to talk through. That's purely for content. And the way you'll get these slides is by finishing the feedback at the very end that I'll send into the chat. So some of these, there'll be a slide on like a full history and how to take it. It's just there for your vision. It's not there for me to talk through it. Um But any questions about them, I'll stay on it then and answer. I just know there's a talk that's happening at seven on the same Zoom link. So I want to make sure that I've got through on mine before that. Anyway, let's get going. So this is just the light and the mood that you're near there. I know it feels like the longest time ever. But you've got a couple of weeks left now and you're off for summer and you've got your best summer yet and the elective summer is so fun and you'll just have a ball. So just know you're nearly there. It's horrible. I've been there, I've done that. It's not nice. Um, but you're nearly there. So what we're gonna cover. So we're gonna do the breakdown of the 2024 sort of um how it's going to run for you guys. Ay, progression of ay some mark scheme, breakdowns, tips and pitfalls Green Card and serious concerns revision tips. A few productions that don't count my money on them, but they're there anyway. And then prizes and tips. So that's how we'll go from here. So I just wanted to put the dates in for a reminder for you guys. So if you haven't already had your P OY, you should be getting it really soon in the Belfast trust as soon. I think it's this weekend and the gals had theirs and I ran that one and then dates of the Aus. That's just for you guys. Just an jo my memory anyways. So how your ay will work. So if you don't already know your stations are six minutes, you get a one minute warning at the very end which will be answer to your questions by the examiner or interpret these results. And it normally says outside the station, you have six minutes to do this at the one minute be you'll be asked to do da da da da da. So it'll tell you which is quite nice. Um You've 14 active stations, seven each day and two rests. So that's a total of nine. Um rest is normally somewhere in the middle, it's somewhere at the end. So if you're number five and nine, that tends to be where your rest stations are. So the way it's typically broken down is two S and G, two peds, two psych, two poem. One will be an AD E and one will be something else. One or two GP one or two, Gerry one radiology, one fracture and one cancer. So I just wanted to clarify that fracture and radiology are separate. We had a radio station with chest x rays and CT s and we also a fracture station because people get that mixed up. Now, that's the way it's always run. But as per your Fa Qs that have been updated for you guys, it says at the bottom there will be three stations per pillar. So your pillars work very different than us. So the division might be slightly off, but it tends to be how long you spent on a placement is how many stations or how many Mc Qs you'll get, have you spent six weeks in Singin, you should get 1/6 of your exam. It should be 1/6 of the AY stations roughly. So that's just to say that it's changed for your year, but typically it was two stations. So I hope these slides are moving. If someone could just tell me that they are, I think they are but just to make sure. Yeah, yeah. Can anyone just tell me that the slides are moving? Yeah, they are perfect. Thank you. Um So if you haven't already seen this, I showed the ones out in the g this this is a breakdown of how much percentage wise that your acies are worth and people don't give them enough credit for what they are. So, although you have your finals and yes, that's really, really scary. 65% of your overall fourth year mark is your Aussies. And the time that you put under your Aussies should technically represent the time that it's worth on your marks. So that's why I always say with Aussies let on often and put the effort in and you'll reap the rewards. I knew I was stronger with Aussies. I spent more time, time on them. My overall score and ranking went up because I spent more time because it's worth a bigger percentage just to be aware of that. And I think in fourth day you can fail three stations, it sort of says there as well. Um But yeah, if you can't find that it's on the front page of the fourth year portal in the assessment section and you finish your progress test, which is great, but obviously you have finals. So that's not too pleasant. But anyway, um so the progression of Oy just to chat about the jump. So first or second year, you have done it. You have passed it. It's the dos, it's the easy history exam. It's one thing and maybe a question at the end and that'll be why did you use this technique? What does the straight leg raise test for? You know, about what you've done? The jump to third year is huge. I spoke to you a lot of fourth years and that jump really scared a lot of people because it's when you have to apply your knowledge and it's history examination, interpreting counseling, it's a lot of information and it's a big jump. But I would say personally, the nicest transition is from third to fourth year because it's very much the same. It's the exact same things that you're doing. It's just different content. You're only covering fourth year content. You'll not be as third year stuff. So it's a very small difficulty jump. You might have an extra to interpret or learning how to do the skills of fourth year stations are more difficult, but in this essence, you shouldn't feel as scared, easier said than done than other years. And then there's another big jump between 4th and 5th, but just to sort of make you feel a bit better about it, the third or fourth year jump is a lot smaller. So general tips, practice little and often and start early. If you haven't started now, it's not too late but start now like ASAP practice with your friends or with your colleagues with a minus one minute. So if you've six minutes, you should have to practice in five. Always practice with a minute less to give yourself time. If you have nerves, look at where you are in the station. If it says you're in a GP, practice, you're in the clinic, it'll put you in the zone and give you a clue as to what that station wants and what you're able to do. There's no point saying in GP, I'm going to get a CT scan. No, you're not, you're going to refer him to the hospital. So look at where you are, what your role is. I know sometimes people don't know what it says in a station. If it says you are an F one doctor, you go on and introduce yourself as an F one doctor. If it says you're a medical student, that's what you do and look at the aim. So always ask yourself before you want a station. And I always said, what is the safety element of this station? What could I get a yellow card for? So if it's an s and you're right, I say chaperone, chaperone, never forget our apps. If it was in any, I just never forget social services, things like that, that are really important and confidence and empathy are key. I'll chat about that in the next slide. For example, if a patient is in pain and they're squirming in their seat and they're saying doctor, doctor I'm in so much pain, be human. Offer them pain relief then and there before you've even go on with the station offer it because that will look really good on your sp marks and your global score avoid jargon. It's easy to say medical terms instead of saying you've cancer saying like you've met, that's too medical for them. So don't say them words, um recognize your limits. You know, if you're dealing with something like an ectopic pregnancy or preeclampsia, you shouldn't be dealing with that as an F one call, your seniors, I called my senior in every single station and fourth year because I'm not going to mark you down for saying once I've done this, this and this, I would call my senior or I'm going to call them and inform them and I'm going to do these things. Um If in doubt ice, Ice, Ice, so if you get lost and you're confused and you've lost your train of thought, go back to ice. Do you have any idea what's going on? Is there anything concerning you at the minute? And what would you hope we can do for you today? And if that doesn't work and you're still lost, do a head to toe, just work your way down the systems and see if you can find what's wrong otherwise, leaflets and follow ups and if you're lost as well, summarizing back to the patient helps you jog your memory and there saying so just to clarify what you've told me today is you've came in with X XX, you feel like this. Um, would that be all correct? And that'll help you remember where you are? Um, if a station doesn't go, well, please let it go. Move on. You've 13 other stations to bring your marks up. If you let it drag into your next station, it can off put you in the full day, just let it go. Sometimes your worst station, which is what happened to me in third year. My worst one that I was crying about was the one that I got a green card in. So your perception of what you've done bad. Don't compare it to your peers. Don't compare it to your friends. It's so subjective in that station. So try and let it go. And another big thing is reading previous years feedbacks. So that's just general tips. As I said, practice, practice, practice with real patients with your friends and small groups and your peers share if you're not competent for your peer, ay, go on and do them anyway, the mark schemes are good. Um Yeah, med do geeky medics sessions. If you can do it with your eyes closed, then you can apply if you can do it by manual without even thinking about it because you've practiced it on the dummy. So many times that when you get into the ay when they start to throw in pathology and start to give you like different things to think about you. You've done it by manual so many times that you don't have to worry about that, you can use that headspace to think about. Ok. What are they going to ask me? What is actually wrong with this patient? Ok. Their, their abdomen isn't in size of gestational age or what could that be like? There's different things that you could use the headspace for. So practice, practice and practice is what I'm trying to say here. Grand. So the empathy station um basically treat the patient how you would your granny, grandad and confidence eludes competence. I seen this somewhere before and I thought it was just like a penny dropped if you give an essence of confidence without being arrogant. But being like, I know what I'm doing, I've practiced 100 times. The sp and examiner is going to take you as a competent person. Maybe you didn't say something in the station you forgot to. But when the examiner is marking you, if you come across really competent, they're going to give you the marks because like, oh, I can't remember if she said that, I'm sure she did and circle it. It's happened before. I've spoke to so many examiners before. It's, it's um it's how you present yourself and coming across as you know, I'm not nervous. It's not saying maybe it could be this, it could be that no it is this or II you have this or you know, come across say your answers directly. Don't say maybe I suppose just say them with confidence because you will have to when you're an F one doctor. So that's my little bit on that. So now into the nitty gritty stuff, I just had to get through the nice little other stuff first. So how the Mark schemes work? Um There is 40 marks excluding the Global Mark and five of them are for how you walk in that station. So you sitting down introducing yourself, getting the patient's name and date of birth and shake or shaking their hand or washing your hands or doing whatever that you do is five marks of 40. So if you do that right, and you're a nice person and you get the simulated patient marks at the end, you've got nine of 40 like it's, it's crazy to think that. So the same amount of marks you're washing your hands as what you're gonna get the diagnosis for. I can't emphasize that enough that you need to get the start bits done normally, like you need to do them properly, know what you're doing. Sorry, that didn't really make sense but you know what you're doing at the start and have that slick. OK. So this is something that they kept asking me in AM Galvan that I wanted to make a slide on, which was what do you do when it says take a brief history, take a brief this and complete a brief history comes with another part. So if it says take a brief history and examine the patient, the brief history is literally what they've come in with? Very, very brief. Are they in pain? Whereabouts is this pain? What's happening with you? If it's an obstetric, you do a little bit about just why are they here that day? Do you have any other medical conditions? Any medications, social family start your examination because the examination should take five minutes. If the second part is take a brief history and interpret this data, you could spend four minutes on your history because data interpretation only take one or two minutes if they had a new news chart or an ECG. So you can take a bit longer. So try and get a full history of whatever the presenting complaint is. If it says, take a brief history and counsel, it all depends on what you're counseling on. For example, if it's H RT or the pill, then you need to get a history that is going to help you aid your counseling. So for example, during your pregnancy, do you have a womb? Have you ever had a breast cancer or clots? Have you ever been on contraception? When was your last period? There are questions so that you can frame your HRT that we had in finals. So that is solely depend on what it is if it's take a brief history and counsel on bisphosphonates, you don't really need to do much. Just more. Oh, well, I had a fracture and they told me I had this and, well, do you have any other medical conditions and run in the family? Are you on any steroids? No grand drug history? So, ok. Well, now we're going to chat about bisphosphonates. So very brief. So that's my one stop shop of a brief history. Queens is very contradictory with this term. If you go through the feedbacks, it'll say, oh, the students took too long of a history when it was brief or the brief, the students didn't take enough. Even a brief should have a drug in a family. So it's about applying your knowledge and in trying in all cases to get past medical drug family and social because they're guaranteed mark. So that's my synopsis on a brief history. It may not be very helpful, but that's sort of the way I did it. I didn't realize how much Queens loved brief histories until I went to do finals. So practice taking focused histories, safety element. I spoke about already. I'm not going to spend time on this slide, but just if it's outside a psych station risk assessment, outside a procedure, is there, Sharps S and G chaperones, peds N A cancer isn't neutropenic sepsis with allergies, fractures as a compartments and think about the things that can get you a serious concern before you walk into that station and make sure you don't forget them. One thing like before you walk in, remember? Ok, I cannot forget to ask for a chaperone before I begin the smear. That is a must. So have one thing is always think about the safety element before you walk in the station. Um, this will keep you away from any yellow cards, but on topic of yellow cards. so you don't feel a station just because you get a yellow card. It's just when you've done something that can be dangerous or come across as rude or come across as a bad, like a professionalism, a demeanor issue. It could be a personal hygiene issue which I highly doubt is ever the case but they rarely, rarely give them out. I emailed on behalf of final years and you guys about our finals to find out. Was there any serious concerns given? Because normally at the end of finals feedback, it'll say there was 20 something serious concerns given out. So Tom Burke had stated that this year, there were so little serious concerns that it wasn't worth putting in the feedback because they addressed the students individually. So that's a good sign. It means they're not being very generous with them, which is good, but just to know you can pass your ay and you can pass a station still with a serious concern, but obviously avoiding them is best. So let's see how we're doing. Grand. I just need a drink now, before I go on with this. Ok. I know I'm talking fast but I'm aware that there is someone on at seven. So if you have any questions, please throw them in the chat and I can get them at the end. There isn't any MSE in this co all about. Ay, so it's not very interactive, but I'll keep chatting. So starting with feeds every year, normally two stations, one's a history diagnosis and management and one's an interpretation station that could be foods growth charts, prescribing something. We had an N A history and we had um uh tonsillitis with a centaur criteria and then prescribing pen B as our other one. So that's what came up before other years has been growth charts. Other years has been different things. So just that wee picture is showing that pediatrics in the top right corner, be aware that if you are doing anything with Children, all the charting is different. So pediatric ay tips. This, if anybody's seen these two slides, it was from my ped stock last week, I've copied them over, but I have a bit more in as well. Just to know that when you walk into a station, confirm who you're speaking to and the relation to a child do not assume it is a grandparent, a parent, a mother and a father, you have to check who they are and get next of kin consent. If it's a granny or a granddad, do not, you do not need a parent's date of birth that happened in the mock Os not MG where they kept asking about. Well, what's your date of birth? What's your list? You don't, don't ask the parents just who are you? What is your name? What is your relation to the child? If it's nanny, I confirm the full family circle and dynamics. So you want to know, do you have any other Children at home? Is the, is the partner you're with the father of this child? Do you have you had any previous partners? Are all the Children at home with the same father? Same mother. What's the dynamic? Get the nitty gritty um and get the developmental milestones as well. So is there a match mismatch between how the child's presented to you versus what their development should be at that age? So that's exactly how ours came up in our ay last year. And what that was was the child had rolled out of bed, but the child hadn't been able to rule yet. So that's how you work that one out for every history, birth feeding growth development. Never ever, ever forget them no matter if it's a co a history interpretation, whatever it is. If you are speaking to somebody about a child, ask about what was the birth like? Are they feeding? Are the toilet, toileting, wet and dirty nappies? Are they growing? Ok. And are they meeting their milestones? Never forget, vaccination, allergies, smokers at home. And I find out a head to toe and something really important when a parent expresses concern about their child, do not turn around and say, ok, no worries. But anyway, as you were saying, or I'm really, really worried, you know, maybe he's got something really serious. Well, a that's grand. But anyway, it's a northern Irish thing most of the time to try and put them at ease, but just watch how it comes across because you've sort of dismissed the parent. So, say I can see this is distressing you. I can see it's worrying you what we can do to help. That is this, this and this. So safety net. All Children with follow up advice as well. So no matter what the station is, if it's a chest, a crip a bronch, um a jaundice, whatever it is, follow up, even if it's not pathological. If it's breastfeeding jaundice, you're still following them up. So that's just some things there, other fee, peds, ts, fluids. Um I've got a slide on that next. So I'm not gonna talk about it. But if in doubt two thirds and avoid potassium for prescribing, as I showed in the first slide, always check at the Peds Cardi and you give medications based on weight or weight or age for antibiotics. Children do not take tablets, Children take oral solutions. So say that on the station and for growth charts make sure it's the correct color for gender and the correct age. So it can say like 0 to 6 or 6 to 1 or whatever it does say. And if you're doing a head measurement on a dummy, it's the same as doing a head measurement on a pregnant abdomen. Use the backside of a ruler, the wee measuring tapes, flip it over, but you do it three times and you take the average, this slide is for vision purposes. I'm not going to talk about it. It's for the guys that I never got to do a PS fluids, talk with them, everything about PS fluids there. What you need when you fill the feedback in, you'll get it at most in ay, they've only really ever asked for AREOS fluids. So it's all there about sodium chloride, sodium chloride and sodium chloride with um DEX. You can get this slide. I'm not going to sit and talk about it. But the big thing to note with this is do not add potassium unless they give you au and E that shows that they have low potassium. And if in doubt and regularly you should two thirds of these fluids in all cases. So this will talk you through it. We don't have time for all of it. Um Other things I'm just going to highlight for you guys for vision that can come up in a is the traffic light pathway know the red. It's the most important know that in less than three months with the temperature thinking sepsis, there are getting admitted. Everything else. Just be aware of the red. That's the most important. The rest of the ones are just there for your awareness. An osk has come up before two years ago for fourth years on Crip. And it asked them to calculate the respirate and it asked was that normal? It's a really harsh ay station. It was a video. So be aware of the ranges. I did not learn them. You don't have the time, know that anyone over the age of 12 is the same as an adult and anyone less than one can sort of nearly go up to 50 even. So I used to remember, OK, over 12, they're an adult, less than one can go up to about 50 anything in between, between that 50 to 15 range try and maybe learn 2 to 5. And that can help break it up for you. So know how to count them, practice counting on youtube videos with abdominal muscles and counter respirate. And it's a pug chart is the most important thing. So na I this came up last year. I'm just giving you for signposting. It's an acronym to help you remember what to cover at the end of a station. If they ask you, what would you do with this child use this acronym and unit uni forms or social work forms that you fill out when you're worried about a child. That's really all there is to say about that. It's a signpost on developmental milestones. You're never going to be able to sit and learn them all. One M CQ comes up on it a year. And if it comes up in your ay as part of your birth feeding growth development, if they're old enough, just ask. And are they developing and hitting the milestones? Ok. If they're a bit young, you might ask. And are they lifting things? Are they grabbing? Are they go g and are they paying attention to you? That's it. I wouldn't sit and learn them. This is just a website to help with peds. Ay, if anyone's interested, as you can tell, I have a little bit of an interest in peds here, but that's moved on. So done with peds now, don't forget the bubbles is great if you need any more resources. So, obstetrics next, we need another drink here. I know I'm going fast guys, but there's a lot to get covered. So these are the common stations that come up, pregnant, abdomen, obstetric histories, obstetric emergencies, diabetic and oral glucose tolerance tests and the numbers and counseling on them. Preconception counseling and antenatal counseling, a pre acomic form of a history exam, interpret and then just data interpretations. So brief tips. I've put on this table. All mums congratulate them on any child. Don't forget it. They are pregnant. It's a happy time. Most of the time. If it's not, still congratulate them, it's important to let them know that, you know, you're happy for them. There's an acronym for any general um S and G history that you should know by now is PPP PMO se, don't forget your GI and your GU and then your B symptoms if it's a gyne cancer, but this is more obstetric focused. So I'll put it in there for your own revision to know, to ask these questions no matter what. At the end of anything, any pregnant woman's come in with, you have to ask these questions for pregnant mums always ask fetal movements. It can be very dangerous if you don't, can sometimes be a serious concern. And on the next slide, I'll show you, but you always ask mums in social history, do you feel safe and supported at home? There's a lot of domestic violence and domestic abuse happens to pregnant mothers and it's seen as an empathy mark as well and a simulated patient mark. And I know that's really bad to say it in Mark's form. But it's really important to ask chaperones for any obstetric exam. Even a pregnant abdomen, you should offer it. It doesn't look bad if you don't um or it doesn't look bad if you do offer it, it looks bad if you don't. So even pregnant abdomen just offered it anyway. Um The common things forgotten I've put in, this is holding the pulse when you're using the Pinard reversing the measuring tape. Um, saying the cervical smears may be uncomfortable but it shouldn't be painful and you're in control of this, we can stop at any time. So that's just some tips here. So now we're going to talk about the Oscar that came up last year. That had a huge fail rate that I could see coming up for you guys. I've said a wee bit of briefness on this for the um al the Galvan crowd. So they've sort of seen this already, but we'll keep going anyway. So this is a growth chart for babies. So this is the pregnant mummies. If you went to any antenatal clinic, you'll have seen this chart 100 times. It's personalized for all mummies. It's done online system and printed out. You need to know how to read this quite quickly in an ay and fill it in with. They gave you a pencil and a rubber. So they had gave us, there was two Xs and Os already on it and you had to put in the next X and no. So if you look down low, the fundal height is X, if you look to the left hand column, it shows you fundal height. So that's what you've measured with your, like your measuring tape. So if you've measured 30 centimeters and they are at 28 weeks, then that's where you go So this one will say they're 27 centimeters at 28 weeks. That's the X, that's your fundal height. Also at 28 weeks, you want to get the weight on the scan. So if on the scan, it says the baby is for example, 1000 g, then at 28 weeks, you go up here and you put a circle around the X but you can put the circle anywhere. So in an ideal scenario, the X and the O should overlap. So there should be an X here with an O on top of it. If that makes sense, I know it sounds a bit complicated. But if you get it printed out one properly, in practice, it's really, really good. So then in our oy, they had been in the middle, in the middle and then they dropped two sent lines. So look at the centiles and show um and sort of sorry, look at the sent lines and see if they've dropped two and if there's a trend and don't forget that if it's in grams and kilograms, they might ask you to change it in this scenario. And if you look at the box here on the right that people didn't notice on the day of OS, it actually tells you they've dropped from the fifth eight centile to the 10th centile to the third them lines mean certain centiles. So I hope that sort of makes sense. Just things to note for your own revision. If they've gone up, what could cause it and some of the risks. So we actually had a pregnant mum sitting in front of us. Now, she wasn't actually pregnant. So the way you walked into the station was, you said to the woman, I've been asked to interpret your graphs today and some of your measurements, I'm going to interpret them first of all. And then I'll have a chat with you. So I went in, filled in the graph figured out she had a small baby and then had to speak to the mummy about what could be causing this. So this is a large baby and then a small baby. So knowing that if it's a small for gestational age, some of the causes and how you'll manage them babies and knowing about like the growth, the unbelievable artery scans CT GS. And then the one that this woman had, we believe on retrospect, I didn't know it at the time was IU gr so we could, we had to ask in history. So I asked you was baby moving. OK. How are you eating? Are you stressed? Are you still working? You know, have you picked up smoking? Have you changed your diet? Like what anything different? And we couldn't really find a cause. So then she asked what's going to happen next with my baby? And then that's when you said, OK, well, do you know we're going to bring you in we're going to do some more detailed scans. We're going to keep a closer eye on you. You might be coming in 23 times a week. You're going to go to consultant like Claire instead of midwifery lead care, things like that. So that's just, I er, that's the management for your own revision. You can look at this yourselves. So I'm not reading this whole slide. This is for revision as well. This is just an obstetric history to have. It's in Oy stop. But I've just highlighted things that are commonly forgotten, which is fetal movements and safe and supported at home. That's it. There's no point in me telling you just, you have to learn it and don't forget G in Gu, which is how are the bowels moving any issues with the water works because that can sort of give way to a lot of different things as well. So don't forget to ask them pregnant abdomen. I'm also not going to sit and talk you through the whole examination, you know how to do it. But ensuring the bed is a 30 to 45 degrees for that. You do not put pregnant mummies flat, they don't sleep like that and also not tilted to one side because it can obstruct the IVC and the flow from the placenta. So keeping them straight and 30 to 45 degrees is really, really important and they will move the bed in all my OSC and finals, I had to move the bed. So make sure you're aware of that. Don't forget end of the bed inspection as well for pregnant abdomens and be careful with your wording for fetal movements. So when you examine the tummy on the outside, don't say, oh, I don't see any fetal movements because that's going to make the mu go. What, what do you mean like that's just don't say it instead say I'm examining for external fetal movements from the outside. I cannot see any movements of the baby kicking. However, on closer examination, when I press on mum's tummy, we'll get a better look. So it sounds, it sounds better. It doesn't sound like oh your baby's not moving because that's going to freak the mum out. So saying it in a way like externally, I can't really see anything at the minute, but I press on mum's tummy. We'll get a better look at what's going on. So say it like that and then just know to palpate the maternal pulse, it's forgot all the time. And this little Doppler if they do give it to you on the day, it has been given before years ago, you put a little bit of ultrasound jelly at the top of it and you put it over the interior shoulder, but you'll not, the thing is with the dummies, they're electric at Queen. So I don't think they have enough to go round for everyone, but just know that, that's what it is and know that it's a Doppler ultrasound and know that that's a Pinard. And don't forget at the, any, at the end of any pregnant abdomen, BP and urine for preeclampsia or C this is for your own revision. I'm not talking about it either. It's just things forgotten and important notes to note with S and G. You can look at that in your own time, get stuff own revision. Again, I'm not going to take you through a full history. Just make sure you ask about STD S all the time. It's not us when we got chlamydia last year and be prepared that it can come up this year in a different way. Always ask your sexual history. Loads of people don't include it just because it's an awkward conversation. If they're 85 years old, you still have to ask it, but just ask it in a nice way. Say, are you currently engaging in any sexual intercourse? Not, are you sexually active? Because that's when all the jokes come in then. So that's a better way of saying it. And have you ever had a sexually transmitted infection? Don't say, have you ever had an S TDI said in my ay for the chlamydia? I've been counseling on it and then said, oh, so like STD S and he was like, what's that? So watch your word in again because that is medical terminology. But I quickly backtracked myself and said, oh, it's just a layman's term that we sometimes use for sexually transmitted diseases. And he was happy enough with that. So, get the exams again. Never forget to ask them to empty their bladder. Um, I got, I think I got a green card for asking that before and one of the ma ones, a lot of people forget that and, um, explained that. Obviously it's uncomfortable but it shouldn't be painful. But that's for you to read through this something that was asked a few times from my peer shares and everyone else was questions on the order of the swabs. So I thought I'd put that in in case you do get it this year. So smears always done before swabs because you can't disrupt the cells inside the cervical Os. Before you do um, a swab, you should do the smear to get an exact sample sort of. So, um the first one after you've done your smear is you do your N A swab and that is in the cervical Os. And that's for chlamydia and gonorrhea. So you'll do that first of all for 10 seconds and then remove, put it in a pot and that's the one there that's yellow. Then you go to the high vaginal charcoal swabs. And for that, it's for BV trichomonas and candida and GBS. So that's the one for pregnant mummies as well. And that's in the posterior fornix. So that's below the cervical os at the back and that's your black one like charcoal. And then you should only really ever be doing this endocervical charcoal swab. If you're checking for gonorrhea and you're doing a test and treat regime, you really don't need it otherwise. And just to be aware that this is a blue swab that sometimes can be used instead of yellow if they don't have them. So I've put them in there, you can read through them and then counseling. This is the last slide for obs and um think of common conditions and how you would word them. Contraception counseling is difficult. It can overlap with GP. So you have to do a brief history before you counsel on it. Emergency contraception, always get the details and was a consensual intercourse. And for HRT make sure you tell them this is not a method of contraception. You are still fertile if they are within that window in the months and stuff. Um It came up in our finals and it was done really, really well, but hr team came up the year before done really, really bad. So it tends to be a trend with queens that whatever was done bad the year before comes up again. So look at our finals feedback, see what came up and have a look now, nothing was done that outrageously bad. It was just the people did so well that some people had to fail in certain stations, but just H RT was done quite well. So I can see emergency contraception slash contraception counsel coming up more this year and practice your wording of miscarriage and topics. They have had to break bad news in finals before of a miscarriage. So be aware, practice it with your friends, know how to word it in them scenarios and explain that this pregnancy is no longer going forward. Um Just make sure you don't word it because some people won't understand the word miscarriage. So psych, I need another drink here because I've been yabbing on previous like stations there for you guys to read yourselves. That's the last like 2.5 years. I've just put them in. Um things tend to cycle. So keep an eye. Um, lamoTRIgine come twice before and yeah, that's just for you guys to have a look at. And our finals was a mental state examination of a manic patient who had bipolar but wasn't diagnosed. They had a recent depressive episode and more antidepressants which triggered them into a manic episode. So this is for your revision. I'm not talking through these all but these are here. So you can use them as a resource how to count on close pains there. Never. Then this came up in ours. Never forget the big four, which is your agranulocytosis, your myocarditis, your bowel obstruction, and possibly just then your weight gain as well. So your bowel obstruction starts with constipation and we get the patients all the time in A&E that are constipated on cloZAPine and then they go into bowel obstruction. So just be very aware that there are four side effects that you have to counsel on. And that's a modern, I, I'm not going to talk you through this. Let him as well is here for your own revision, know the dosing. And when you check the trough levels and peak levels know that you normally give the first dose at 10 p.m. at night so that you can check the next level at 10 a.m. in the morning because the first one has to be 12 hours. Other than that, there's a side effects. Big thing with nothing is kidneys. Um So you say like it makes you hold on to water, it makes you thirsty. Um It makes you go to the toilet more often and when you hold on to water, you look like you've put on some weight, think all things kidneys and know the difference between um a mild tremor and a course tremor and actually show the patient this is a mild tremor. This is a course tremor. It's really good to explain it to them like that suicide risk assessments here as well. Once again, it's for your own revision purposes here, I've put it in um things to note is weapons and farmers and policemen. So if someone says they're a farmer, do they have access to machine guns? Do they have access to fertilizer? Dangerous things and policemen weapons as well. Um, that's quite common and always get your whole before during and after and even then still, like you have to do your risk assessment even though, you know, they're high risk because they just tried to commit suicide. But you would say if you were to leave here today, would you consider doing this again? Do you still have thoughts of life, not worth living? Do you intend to harm yourself or others? Things like that? So I'm just gonna keep an eye on the chat here. It's all going good. So mental state exam just because he came up in our finals and put it in as well. I learned it as ABA PC. Everyone has their own way of learning it. This doesn't really make sense to anyone but me. But the first three was what I could see and the rest was the questions I had to ask. So appearance, how did they look to me? How were they dressed, how were they acting was behavior and then how was their speech? The thought affect, mood perception, cognition were all questions I had to ask. And a very commonly one forgotten this insight and that'll dictate whether they need detained because you have to ask them. Do you believe that? Could you challenge your thoughts? So if I was to tell you that this didn't actually happen or that them voices actually aren't there? Could you, could that be possible. And if they say, oh no, absolutely not. These voices are definitely here. They have no insight. But if they say, oh, well, do you know possibly but maybe not like in our O CD station, um they had insight, they didn't have, they knew that what they were doing was irrational, but they couldn't help themselves. So always ask insight. Practice on youtube. Watch the ques meed videos. There's some videos of manic patients and practice to yourself or to your friends. How would you describe this youtube video? How would you describe this patient? Because we had to take a history and then present our findings back as a mental state exam, the mental health order as well. This is in your predictions for me. I'll tell you about that then, but I would say that you would get this. So you have to know what the criteria is that a patient has to be suffering from a mental disorder and they are either the rest to themselves or others to themselves or others. So being aware of that and knowing your forms. So I've put the form summary here. I've shown how it works. The two main things is detention for assessment brings you up to form 10 and that lasts two weeks and then detention for treatment can last up to six months. Um I've put that graph in that hopefully, you can visualize it a bit better on how it all works. And um just keeping an eye here to say no one's putting anything on the whatsapp chat and also offering family members tribunals. So they tend to ask, oh, I don't really want my son there or I don't think he should be detained. And he said, well, if you have any, you know, issues, we can have a tribunal meeting for yourself. And then normally family members are happy with that. So that's just a summary table of the forms for you guys to use again in your own revision. I know I've said that a few times but I just want to give you resources. So um yeah, that's it to go through. Know that there's a few rounds. You can remember. A six for a nurse is six hours. A five is a ward. Um A two and a three is, everyone needs a two and a three. And yeah, there's a few other wee ones there like uh 48 hours for form seven and within seven days of form seven, there's a sevens and eights. I could sit here all day and chat you through them, but it would take me a good half hour or so. I'm just gonna keep moving. So, anesthetic station as well. We're on to the next one here. Um You guys have the ace and your anesthetics isn't the finals, but you have had a Ls of Queens or I LS in the royal as part of your ace. You've had to do cardiac arrests in cardiac arrest, you have to manage airways, therefore you can get airways. I went through your curriculum and I read it and you still can get asked anesthetic stations. So you need to familiarize yourselves with the equipment and the resources that you can use to manage an airway because a lot of the fourth years at mcal hadn't been very familiar with it. So we had to put on a session to sort of bring it up to speed. And I'm aware if it's happening at MCG, it's definitely happening in other trusts as well. So get into the SIM suites, get onto the wards, go up down, aesthetics, ask them to talk you through things. It's really, really important that you're aware of how to use this equipment because you can tell when someone's holding a gel and we don't know what it is. If you don't handle a, a, that's a serious concern because an airway is what's going to kill you first. That's why it's first. And if you move to B and do that on oxygen and you haven't managed a strider or an anaphylaxis, then that's a serious concern. So anaphylaxis is an, a problem. Know that adrenaline happens at a as well because that's you treating an, a problem in 2022. In 2021 it was a full station on airway management. It was a dummy and it was all the airway devices and the examiner just asked questions. Can you show me what device a gel is? Can you show me how you would size it? Can you not insert it? Ok. The gel hasn't, what would you do next? And that's how they did the whole six minutes. So it was a dummy head. So make sure you've practiced this and know all your contraindications to your devices. So I've put this slide up here. It's on the portal in the fifth year portal on the assessment page. And it shows you what the three signs of a successful ventilation are kind of shows you how to insert them, how to size them. You will not have to do ET tubes. You just have to know when would you do intubation or if they say this hasn't worked, this hasn't, hasn't worked. What would you do next intubate? And it's obviously just helpful to understand the names of the equipment. So that's for your own of vision to read through that. Now, the A&E a station that you'll get, um you don't have to get an anesthetic station. So we got an ABCD and an S VT. So you don't have to get it. But if it comes up, which has come up two years in a row before, um it'll be an airway with a dummy. So anyway, your poem stations, these are just general tips. Don't forget your end of that assessment. Make use of the instructions outside. You will get 180 e without a doubt in your fourth year. And the second one could be an airway one or it could be a history of SVT or it could be an M I, it could be an E CG. It could be anything. Queens don't give you monitors and Queens don't give you like, um, screens. And if you ask the examiner, what's the heart rate or what's the BP, they're not going to tell you most of the time they will leave a printed out news chart beside the patient and you'll have to interpret it as you go. So make sure when you're on B and you're asking for the oxygen sets, they only look at the oxygen and the respirate. Don't go down looking at the BP when you haven't finished your B assessment because that will go not well on your marks because you've shown that you've skipped steps. You haven't listened to the chest, you haven't checked for tracheal deviation. So only look on the news chart for what's relevant to your B assessment, your C assessment and then your d look around the room for prompts if you're stuck, make sure you check the patient name and date of birth on the news and on the fluid balances and on the drug card, know how to take a sample history. I've got it on the side over here. Make sure you meet and treat when you are met with a problem. Treat it before you move on. Otherwise you haven't managed that area of ABCD E, but I'm sure you all know this by now. Get comfortable with a slick assessment and some common ones that come up sepsis seems to be every year, come up with another year with a POSTOP bile per postoperative complications come up. Opioid toxicity, DVTs P ES myocardial infarction, asthma COPD. Sometimes it could be an NG tube with a chest X ray. After not, you'll never have to put them in. That's not part of it because you do that in final year as part of an actual assessment. So that's not coming up. Um You can get chest X ray with a pneumothorax. You can get an ECG with SVT and also know how to do a G CS assessment without using the G CS performer. They asked us to do it in finals without giving us one. So although they say they'll give you the charts, they'll give you this. No, they won't. They didn't give us S VT algorithm for our S VT station and they didn't give us a G CS sheet for our G CS station. So you have to know your tachy arrhythmia, your brady arrhythmias and your G CS proforma. So let me just check the chart here while I'm yabber on Grand. What about extra time? I gotta make a move here? I keep going. So there's just a performer from OS. You stop, you can read that in your time. There's a GC sGC S performer. If in doubt, every patient should get a chest X ray, an E CG and an ABG, they'll stop. Just give it to them all. It's doing no harm. Sample history. If they say outside the station of an ABCD, take a brief history and perform an assessment on the patient. This is your brief history. How are you feeling? What symptoms are you having at the minute? Um, do you have any allergies? Are you on any medications such as drug? When your past medical? Um, do you have any other medical conditions? When did you last eat? When did you last go to the toilet and like the events leading up to that? So what if it was a car accident or something? But you're not getting traumas in your acies? That's more like prize exam stuff. So next one, we're, we're making to move. So cancer and palliative care. So, um, these are the previous stations you can read through them in your own time. I couldn't seem to find any cancer palliative one in finals. So it could come up for you guys neutropenic sepsis last year came up in final and people gave the wrong antibiotic because they were pen allergic. So, therefore when it came up bad in finals, it came up in our fourth year because there's only four months between them. Nothing for cancer and palliative came up in our finals So I don't know what will come up for you guys. I can't say, oh, this was done bad. So it will come up. But that's just something to be aware of for your own revision. Here's the emergencies know for everyone that it's 8 mg of Dex po BD plus A PP A A Eden co loves it. Just know it. You're breaking bad news. If you haven't already seen do your spikes, I've put it in there as well. Um, important things that you can do to help with that station is when I know it's a breaking bad news. Before I go in, I look around the side of the door to see sort of where the examiner is with ipad and where the patient is. And I walk into the examiner first of all and I say I'm going to turn off my bleep, the door is locked and I have my Macmillan nurse with me here and then I walk around to the patient and say hello. My name is just so you've got your setting marks and also watch how you come into the room. So if you come into the room and say, oh hello. My name is Nicole and Da da da. That's a wrong demeanor that is coming in with good news and you're cheery and you're happy. It's one of them ones, you have to dial it back a bit and sort of go. Hello. My name is and like a lot of a softer, gentler tone because you're setting a scene for delivering something that's not very nice. So, practice it with your friends, practice it in uncomfortable ways for our GYA station that was chlamydia. People broke bad news in our finals. I didn't, and I didn't do bad in it. Um, I don't see how it could be bad news when it's something that you can cure. Breaking bad news is a lifelong diagnosis or it is a cancer of some form. So sometimes diabetes can be breaking bad news like the way that you set it up because that's a lifelong condition or telling someone they have something chronic or a miscarriage and ectopic of cancer that's breaking bad news but something you can cure and fix. I didn't do it for my, my gain one. But just to be aware, everybody each to their own, this is for your vision. I'm not talking about it. Here's how you could do chemotherapy. Here's how you could do radiotherapy counseling. And then now we're on to geriatrics. So previous stations there that have come up, the N I HSS partial is the thing on the right here, but they were only asked to do part five and part six. So the rest was filled out and once they'd done part five and part six, they then tallied it up at the end and got the overall mark. So that's the recent ones that have come up here. And I'm gonna talk more about them now. So we got a stroke phone call last year. Never hung up the phone and always find out where they are in their address. So stay on the line and say with your imaginary other phone. Ok. So I'm really worried about you here. Now, it's possible that you could be having a stroke. So once you stay on the line with me, now I'm going to ring an ambulance. Can you confirm you live at da da da da da? Ring them and then once you've done that, once you've confirmed it's a stroke, you rang your ambulance, then you take the rest of your history. So that's when you go into past medical drug social, all that they'll try and throw you. Oh, well, I have aspirin here. Can I take it? No, you need to rule out a hemorrhagic stroke before you give anything like that and they will challenge you on it. Oh, no, my neighbors next door so I can go and get them. Don't move, don't eat, don't swallow anything. Gag could be not intact anymore after a stroke, depending on where it is. Um Just sit still, don't move. An ambulance will be on their way. That's it. If a family member is there, get them to stay with them. So, yeah, that's the stroke one and that can come up as ami as well. It's come up as a heart attack. The delirium one that we got is here and I've put in the four at, I've told the guys not in the Galvan that you don't need to learn all the N I HSS the Barthel, the pinch me, the, the A four A Well, you know, pinch me but the four at the Rockwood, all them or whatever you call them. You don't need to learn them all off by heart. What you need to be aware of is what each one is four. So N I HSS is for stroke and you need to know them. Plus then you need to know does a high score mean a bad thing or a good thing. So what could be high in an N I HSS is bad but in a Barthel, a high could be good. So know what that means, be able to interpret it but you do not need to learn all the components. You need to however know a pinch me, know it off by heart. It came up in the finals. Make sure before you do a delirium assessment that you have a collateral history that you can ask a relative and that you're able to evaluate all charts. So we had a fluid balance chart, a card X and A news. And the patient had been up for paracetamol, which hadn't been given, they had a catheter in that had like red and yellow urine, um sort of give off infection really. And they had a sputum cup beside the bed that was yellow. So, observe your surroundings and see what there is that could indicate a cause for your delirium. And um so what else do we have on here? Pain? Um, opioids. Yeah, that's really it bile charts, you know how they open their bile and are they moving their bile and things like that? So we had a nurse in ours, make sure if you have another colleague, like a nurse or a doctor or whatever it is that's acting in that station that you address them, get their name and ask them and what's your concerns at the minute? What do you think is going on with Mrs Smith today? And what are you thinking? Ok, let's run through these causes. Now. Could she be in pain? Has she been giving her paracetamol? Has she gave off any signs of infection? You know, she, is she burning when she's going to the toilet? Is she sore tummy? Is she coughing a bit there? And has she been eating and drinking? What's her fluid balance? Like, like ask the questions in a very, you know, like a colleague way. You don't have to be a robot when you ask them grand. So Parkinson's came up in finals um and can come up before um whenever are we on now, we're nearly there. We've got 10 sides left. Um It's a video mainly if it's fourth year, we had to do a upper limb neuro exam for our finals with a real Parkinson's patient. Um, if you get a video for Parkinson's do not state things that are not there, you will get marked down. People learn, learn, ok. They have a pill rolling tremor cog. Well, rigidity, it's unilateral. They have a shuffling gait. If the patient isn't shuffling, don't say them things because you're not going to get the marks. It's just not happening. Um, it's came up in feedback before that students have imagined things that were not there. And in our finals, it came up under Parkinson's that patients said or shouldn't have said things that weren't there and then just know that it's a family diagnosis. So just when a relative gets diagnosed with Parkinson's as much as we want to support them, we also want to support the family and the community around them and think about ot moving the house physio, um mental health support, social support, memory aids, things like that. Um Gerry's drugs, I'm not talking about it. Bisphosphonates are there. That's really the only one. Be aware of them. Other geriatric stations that have come up are here. You can read them on your own time fractures. Here's your stations here that um have come up before nothing came up in finals for fractures. Um Compartment syndrome was in fourth year and our radiology station was a pneumothorax with a CT with a bleed. Um So how to do a fracture. So this osk stop is really, really good on how to do your fractures and how to interpret them. I would just learn this off by heart. But to note, know the rule of twos. When you get an X ray, ask, can I have two views of this X ray? Do we have two for previous comparison? And two joints? So for kids, the joint above and below, if it's a wrist, sometimes with um the, not the collies ones but the oh, what do you call them? Now, the one you get dislocation at the elbow and um a fracture at the ulnar like by one. So you want to ask for wrist and elbow that there's not much more for me to say other than fractures other than if I went back a slide there, just that hips are really, really common. Hip pain, lumping child is a hip hip again, just know your garden classification, know your hip stuff really, really well and possibly qualities. Um If you get a compartment syndrome, remove the cast, I did not. So that's just something to note for you guys. So I'm not gonna talk through this either because you have got this for four years, but chest X rays do come up. We got a pneumo and how to manage a pneumo and he would refer to. So just for highlighting them there and the same with an abdominal X ray, that's the queen's performer there just to be aware of them Oh, sugar, sorry. Um Where were we? And then CT S you will not have to interpret a full CT head. It was name date of birth H and C what is the obvious abnormality? And I think it was an extradural in my one. I can't remember what it was. Now, it's in my notes somewhere and for your M CQ, the head CT guidelines do come up quite frequently. So just be aware of them because it does come up and your bananas and your lemons if you haven't already heard of them. But yeah, that's for sure. Vision purposes GP station. Ok. We're at the last topic now. Great. And what are we like for time? Ok. Grand. So um N A guidelines um that's really it for G PGP will overlap with Gerry's all the time and GP will be a station of its own. So we get a cough history. The only thing looking at for GP Acies is look at a cardiac arrest and an abdo history, never the examinations. They're not going to waste them for 1/4 year station. But know the histories and know your N A guidelines because most of the time it's something to do with red flag referral pathways. If it's a colorectal cancer, if it's a lung cancer, we had a cough and the referral pathway is an un resolving cough, you have to do a chest X ray to rule out lung cancer. So that can diagnose COPD. So this patient has COPD in our case, that's really, it GP will overlap. It could be GP with contraception. That would be an overlap as well. And they're the common cancers, breast lung, colorectal prostate and gyna. Oh, I'm nearly there guys. I promise my, I have such a dry mouth now after all this yapping. But anyway, um counseling drugs. So ice is here. How to ask it. Do you know why you're here? Do you know anything about this drug? Any concerns you? What would you like to know? And the best way to do a drug counseling is to say, so, say we're going to talk about starting a contraception pill. What that will involve is chatting about what it is, how it works, how you'll take it when you'll take it some of the side effects and how we'll monitor you. How does that sound? They'll say, yes, that'll help you jog your memory of what you need to cover and then I use athletics, find a way that works for you and just go with it. I always use athletics and I'll be sitting and being all right a, ah, with my fingers. So that's one way of doing it and then a leaflet as well, counseling conditions much the same, the same ice. Do you know why you're here? Do you know about this condition? Anything concerning you? And then I use, normally we can probably manage for a condition. So, Yeah, I'm sure you've heard it in third year and it's everywhere. But normally what, what happens in the body is what, what happens when you have this condition is the cause of this condition is the problems and the management it come up under peas with eczema we had in finals or asthma or diabetes in Children. If it is a counseling station or counseling on preeclampsia or, um, what do you call it? Um, diabetes in pregnancy, green cards. I just want to say, don't beat yourself up if you don't get them. It's great if you do. But they're very subjective. The station you think you've done really bad in, you can get a green card one that you've got full marks in. You could be top at that box spot, the very, very top. It doesn't matter. You could not get a green card. They're great and they're good confidence boosters, but they're not the end of the world. So they're there just a note. It can be very subjective. But yeah, I'm nearly there for anybody that's on for the next session. Um because I can see people will probably start joining now. So there's your predictions. Um It'll come through now in the um powerpoint that you get when I send it out, I think you'll get preconception, diabetes, something with OG at an examination station, ps vaccines. I seem to think that might be a thing. Suicide psych, a mental health order. An X ray for a fracture radio is always the same. An ABCD for poem, a breaking bad news for cancer and a FS for Erry. That's my guess is, but don't put any money on me. Just a note on the fourth year portal. If you go on peer share and click fourth year peer share, it'll bring you to an AK library. Here is 123456789 AY stations with Mark team. Go look at them, practice with them. They're very accurate to Queens. Also on year five assessment for resources. If you go under, you can see a year five A library which shows your five stations. Half of them are irrelevant to your four. And there's loads of resources here on the year five portal so that you guys should all be using as fourth years because there is a lot of fourth year content on there. Prizes for ay just quickly, there's one every year for Ay if you're interested in them, they're there. The fourth year ones, the Jack MLU prize and you get a bit of money, um resources to use. So the highlighted ones are what I used um feedback, feedback and previous feedback is your best resource. The med portal which I took you through. If you go on to assessment information os, there's loads a stop and me. So the if you download GKI Medics subscription, I think it's like 40 lbs for the year but if you download it now that'll do you for your final, your ays next year. So try and time it because my subscription just timed out like two weeks before a, so I had to borrow someone else's because I wasn't paying 40 lbs again for it. But, um, yeah, so get the sub now if you haven't, so that it'll do you for your o next year. And the rest of the resources are ones I took off the portal are fine and people have used, I used the highlighted ones. There's a lot there to use but don't saturate yourself with too much stuff. Oh my goodness. I have talked and talked and talked. Let's see now. So this is the last slide. Any questions for me if you want to unmute or write in the chat and my email is there. It's a 3 to 5 working day response weeks of the time. But I will try and get back to people when I can um any questions and I will send in the feedback so you can all get the slides now. And if the people who are talking after me want to talk, so I know that they're here. Um How do I stop Sharon? I see. Oh There, stop sharing. Grand. So let me give you this feedback. There someone on mute there that wants to have something. Yeah, I talk. Oh Next talk grand. I'll get a seat back in two seconds. Just to give it to these guys so they can get the slides. Oh, my goodness. I yabber and yabber but II 80 slides. So I really had to talk with like, um, and here is the feedback. So if you just fill that out, you'll get the slides. Um, hopefully that was helpful. Good luck on your Aussies. That's all I've got to say. Now. Um, grand, the, the, the, the, if in a, if in a ped station and as a foster parent, do you need to gain consent from the biological parents? No, he would not have to do that. A foster parent is a legal guardian. So you wouldn't have to do that. Um Yeah, that's really it there. You could just say like what's, if the child wasn't there in front of you, you could ask what's the dynamics surrounding that situation. But otherwise, you know, I don't, don't think so unless um him or anyone disagrees with me. Um How do you gain next of kin consent if grandparent in a station? Um So that's just saying to them. Have you asked the mother if it's ok that you're here today? Are you the legal caregiver? Like do you, do you babysit your grandchild? And if they say yes, you document in your notes, I would document that the granny has got consent from the mother in the ay, you will have absolutely no time to do any of that. But just saying, are you next of kin is enough. If it was like, um a legal guardian or if it was a granny and does the mum know that you've brought the child here today? And if she gave consent and in the o they're always going to say, yeah, she said it's fine. Yeah, that, that, that's the crux of it. Um Grand. I don't think I have any other questions here. Hopefully not until I can get let the other guys get started. I have Hema your feedback for yours. Um Are you talking for how long to what time you're muted there? Sorry. Yeah. Um Hopefully not for very long. Hopefully half an hour to 40 minutes max. Ok. I will set a timer on my phone because I'm gonna leave my laptop running and I'll come at like half to like send it in or like 35 minutes pass and then I'll come back in for emer to send her. Yeah. Cool. Grand. So I have no more questions there. So let me see. Um Yeah. Do you want me to stay on to see if your your powerpoint works? Um Yeah, it should be fine. I'll try and share it now. Um Let's see. Oh, I've got a dry mouth. I yabber and talked for a full hour and did not stop. 00 my goodness. Me, there's just a lot to cover if you cover the context of A II know like 50 slides in 30 minutes. Like that's, you made me feel better. That's fine. Uh, we'll see, I just have Uber slides with me, so I had like a few funny ones but like two or three. Not really that much. Anyway. Um, uh, can you see that? Yes, I can see that. Do you wanna make a full screen to see? That's just on the normal screen just to see if it works and then I can. Yeah, that's perfect. Ok, I'm going to tap out here, but I will come back in like in 30 minutes time and send feedback in. No worries. Um, I'll just get started then. Um, so my name is Hema and I'm one of the fy A zero. so I'm giving a talk today on general surgery. Um, there's a lot to cover. I understand. I don't know if some of you maybe fourth years, some of your third years. So a little bit of both M CQ and A today. Um, so we'll see how much we get through. Um, I don't wanna keep these for too long. Um, so we'll first start with, um, just what we'll cover today. So what I decided to focus on was because gen surge as we know is quite a large topic. Um, so I think the acute abdomen is quite important both in terms of M CQ and OS C. Um, we have biliary disease, very commonly comes up diverticulitis and obstruction. Uh, and then very brief briefly bowel ischemia, hernias, colorectal cancers and stomas, POSTOP complications and perianal complic uh conditions, um, less high yield, still quite important. Um, and if there isn't enough time today, um, the slides are there for you to look at in your own free time with the sufficient information. So we will start with the acute abdomen. So, um, I don't know how many people are on this call, but let's start with, um, a little bit of a question. So um just type your answer into the chat or you can call it out if you'd like. So, a 20 year old with abdominal pain 12 hours ago, um mainly on the lower right side, nausea and vomiting. First episode of the pain, last menstrual period two weeks ago. Um Her temperature is 8.5 P 100 BP 1 20/60 tenderness and guarding in right leg fossa. So, what do you think is the most likely cause of her pain? Um Though to be fair, I do understand it's probably not many people um at this point, but uh that's OK. We can just do one. So, um yeah, OK. So appendicitis. Um So correct. Um Right, like fossa, you'd always wanna think um of that kind of differential. I would wanna say that um it is also um if this was an ay and if you asked for the next investigation, you would also always say if it's a woman of childbearing age a pregnancy test always very important because you'd always wanna rule out an ectopic pregnancy. Um So I'm just gonna cover just the slide here. So I think it's quite important in both an OS setting. Um and even M CT setting to be quite familiar about where pain presents. And this just means that if you're doing an abdominal exam in the os tu setting, you can list off a bunch of differentials to your examiner or when you are doing an M CT, you can think about um where this pain is and what it could be so very quickly. Just in this epigastric region, you would think of um peptic ulcer disease, pancreatitis and a ruptured AAA. Um right upper quadrant, very popular with um cause you think what's there, the gallbladder and the liver. So you would think um bilary colic acute cholecystitis, acute cholangitis would be your top ones could also be liver pathology. Your right leg fossa, acute appendicitis. As that question said, ectopic pregnancy and um ruptured ovarian cyst, um ovarian torsion of my diverticulitis as well. On the left hand side, you would wanna think of um diverticulitis is quite common. Once again, ectopic pregnancy and gyne pathology and always with acute abdomen. If it's a female patient, always think of possible gyne pathology as well cause that's equally as important and um equally as common and then your typical loin to growing pain, you would think your renal colic pyelonephritis, your kidneys could also be ruptured AAA. And um you'd also think suprapubically kind of where your bladder is. You would think of a uti acute urinary retention P IDS, pelvic inflammatory disease or prostatitis. In a male patient centrally ruptured AAA intestine intestinal obstruction, ischemic colitis or your early stages of um appendicitis. I would say with the acute abdomen, it's important to be aware of like peritonitis or uh peritonitic picture where you know, it's inflammation of the lining of the abdomen. And so this then means that if say you were in your asking, you were doing an abdominal exam, signs of peritonitis would include guarding rigidity, rebound, tenderness, coughing, tenderness or percussion tenderness. So it's very tender to touch, especially in a particular region. For example, if you're touching the right eac fossa and the patient, you know, is in significant amount of pain, um You would think that, ok, this could possibly be like appendicitis, you'd be worried about like ruptured, um peritonitis can be like localized. So in the case of like appendicitis or cholecystitis where you know, it's just the appendix or the gallbladder that is being inflamed. Um or it can also be generalized in the terms of like a ruptured appendix or um like a peptic ulcer disease, rather like a pep peptic ulcer. Um because that means that contents have been released into the peritoneal cavity. And so that causes generalized inflammation. So your whole abdomen would be um quite tender and then another thing that you could do in your abdominal exam is if you look at the patient from the side while the line, you know, that's, it's the para genetic picture because they're, they're in so much pain from the inflammation. So, um moving on to appendicitis, um very common. So what's important is just to know the pathophysiology behind it. So the appendix is a single opening. Um It's kind of at the end of the cecum and it basically the way that it is anatomically allows for pathogens to get trapped. Um Most of the time, this could just be fecal matter. This then leads to infection and inflammation causing gangrene and rupture. So your signs and symptoms of how your patient would present abdominal pain, typically starting in the umbilical region, but then moving to the right leg fossa and then they will have um loss of appetite, nausea and vomiting and um fever as well. Um You also have the roughing sign, which is when you press on the left hand side, it causes pain. On the right hand side, you have some guarding and rebound and percussion tenderness differentials of appendicitis is ectopic pregnancy, ovarian cyst meckel diverticulum or mesenteric adenitis, and you would manage it by the appendicectomy, um or laparoscopic surgery. Basically, um two things is. So the two differentials methyl diverticulum, you would follow the rules of two. So 2% of the population is affected. It's two times more common in males. Um It's located 2 ft proximal to the ileocecal valve and it's two inches in length. Um and the mesenteric adenitis, I think this is quite a common M CQ question. Um But if it's a recent infection in a younger population, you would suspect mesenteric adenitis. And um in a female patient always consider a pregnancy test as your initial investigation. So next, we're moving on to pancreatitis. Um another quite common um presentation. So basically, it's just inflammation of your pancreas and it can be either acute or chronic. So this presents with severe epigastric pain, um that radiates to the back and the patient would be vomiting would be systemically unwell on examination. So you would have tenderness in the epigastric region. You could also you can see in some patients um bruising. So this is either umbilical bruising. So that's called colon sign or you could have bruising on the flanks and that's called gray turner sign. So if this was an asking, you were asked to order investigations, you would be looking into F PCU ne LFT S, um Calcium ABG and amylase and lipase. Um So amylase is quite useful for acute presentation of pancreatitis, but it needs to be very, significantly raised cause it's not a very specific marker. Serum lipase has a longer halflife than amylase. So, for pre presentations, that may be delayed, that is sometimes an investigation that was preferred. Um and you would also get C RP for inflammatory markers. You would do um an ultrasound or a possible CT abdomen as imaging. In terms of management, you would take um an at approach to head to toe assessment of the patient. You would wanna give them fluids because um with pancreatic patient can be quite dehydrated and there loss of fluid into the third space. You wanna make the patients know by mouth cause we might need to um get to surgery. But also just um so that you are monitoring what's going in and going out and then give them analgesia and treatment of gallstones. And this is because the most common cause of pancreatitis would be gallstones followed by alcohol, um and then antibiotics as well. Um And so here I have the causes of pancreatitis. So yeah, gallstones, alcohol and um ERCP procedure um that can be done. Uh probably your most common cause the the pancreatic also the complications. So you have necrosis infection, um abscess formation, fluid collections, pseudocysts and chronic pancreatitis. And then just be familiar with the Glasgow score that's used to score just the severity of pancreatitis. Um And I think it will be quite useful for MC QS. So with acute pancreatitis, you wanna be careful because that can precipitate acute respiratory distress syndrome and um Y serum lipase is more useful. So, moving on to chronic pancreatitis. Um So with chronic pancreatitis, um it's basically when the pancreas is chronically inflamed um and the tissue function of the pancreas is reduced. Um And so, key complications is you would get the chronic epigastric pain. You would lose the function of the pancreas. Pancreas has exocrine and endocrine function. Um It will cause damage and suggest the duct system and then you would form pseudocysts or abscesses. You would use um a CT abdomen as a um investigation. As you can see here, the arrow is pointing to just calcified regions of the pancreas suggesting chronic pancreatitis. Um In terms of management, you would um just wanna abstain from alcohol or smoking. Um You would take some analgesic, give patients some analgesia because the pancreatic function is reduced. You wanna replace this with um some enzymes and you wanna give them insulin as well because once again, reduced function you would do and you could do an ICP with stenting, but then your last line would be surgery. Um And so a um excessive alcohol intake is probably the most common risk factor for the development of uh chronic pancreatitis. And um and because of that, the inflammation will destroy the cells as well. So then that also leads to consistently high glucose levels, which is why you probably wanna supplement them with insulin. So, yeah, most common risk factor and a useful test to assess the exocrine function of the pancreas is fecal elastase. So next, we're gonna move on to gallstones and biliary disease. So just in terms of gallstones, so bile is produced by the liver stored in the gallbladder and the gallbladder will act as a reservoir for bile. Um, and then the gallbladder then releases this bile into the duodenum of the small intestine. So, with bile, um, so I'm just gonna say that. Ok, so, and how does get, gets released is basically when you eat and um you ingest, you know, your food, food may contain fat and when fat enters the digestive system, this causes um a chemical called cholecystokinin um to be secreted from the do um duodenum. And then this causes the gallbladder to contract and then that causes the bowel to be released to the duodenum. So as the gallbladder stores the bile, this is where um it may lead to the formation of gallstones. So in the gallbladder, you could have. And so that basically, sorry. So when you have the formation of gallstones that kind of affects your um release, and we'll discuss that very shortly, but basically gallstones can be divided into three main types. So you can have um cholesterol pigment or mixed and you have your risk factors there. They like to use the four Fs as a mnemonic. So if you're, you know, fat, so maybe just overweight, female, fertile and 40. So just your age, your sex and just, um if you know, in terms of like obesity or not, depend depending on how the patient presents. So in terms of clinical presentation, you can have gallstones and you can be asymptomatic, but sometimes you may, or the patient may present with symptoms. And so what those symptoms may be is typically right, upper quadrant pain. Um, and if the gallstones are affecting them but not affecting them continuously or it's not an acute, um, picture you would have bilary colic. So, with bilary colic, you have severe right upper quadrant pain which comes and goes and that's associated with some nausea and vomiting. Um, and it's associated with certain types of presentations. Um, sorry, complications. So, moving on, these are just the effects and complications of gallstones itself. So, you have acute cholecystitis, which is um when the gallstone is in the cystic duct and then you also have acute cholangitis and this is basically causing obstructive picture in the patient. Um So, obstruction and infection in the common bile duct. Um And so choledocholithiasis is a stone in the common bile duct. And then when it's um infected, that's acute cholangitis, you can have cholestasis which is blockage to the flow of bile once again causing an obstructive picture. And you can have gallbladder hye, which is collection of pus in the gallbladder, um which will be very effective for the patient. So, um one thing to note is that gallstones very common cause of pancreatitis and the gallbladder empyema is basically resulting from unresolved acute cholecystitis or mucosy becoming infected. So then with these presentations, you could also have mei syndrome, which is basically a gallstone in the cystic duct that is impacting obstructing the hepatic duct. So there's black flow backflow of bowel to the liver and that's obstructive jaundice as well. And then you'd always want to be kind of, your red flag would be um, a palpable nontender gallbladder because that's just warning of a more sinister diagnosis. And basically, if a patient presents with painless jaundice and a palpable gallbladder, you would be worried. So, in terms of clinical presentation and diagnosis, um on examination, you would have tender, right upper quadrant pain, you would also have this pain possibly radiating to the right shoulder. And when you're examining, you would try and examine for Murphy's sign. So that means that this right upper quadrant tenderness is exacerbated when the patient is um taking a breath in, um and positive signs suggest acute inflammation and on blood. When you do your blood tests, it may be associated with mucositis um and moderately elevated LFT S. So, um investigations you do is abdominal blood. So your F PCU EC RP, um amylase and um LFT S and then you would get some imaging done as well. So, ultrasound is normally your first um kind of investigation that you would like to do and then you would also do um an M RCP to see the biliary tree to see if there's any obstruction of stones or anything like that. And you could do an MCP as well. Um This is just in terms of presentation. So with the biliary colic, you would have right upper quadrant pain, but you don't really have infective symptoms and you don't have any obstruction with acute cholecystitis. You have right upper quadrant pain and you will have, you might, you most likely will have fever and raised white cells and inflammatory markers. But you don't have jaundice and with cholangitis, acute cholangitis, you would have right upper chin pain fever and jaundice and that's known as Charcot triad and from Charcot triad with very, very severe acute chitti, you could get Raynaud's pentad, which is the right eye quadrant pain fever, raised white cells. You would get um jaundice, altered mental state and lower BP. And I think another good thing to know just for exams and for OS as well is um just your LFT S and interpretation of that. Um So basically with the, sorry, I think I'm still, yeah. So with the LFT S, um you just wanna see about the, in terms of the obstructive picture. So trying to interpret kind of your, in terms of cholangitis, then you would get um A raised E LP and A raised GGT as well. Um And then your lipase and amylase might be raised in terms of transaminases. So your ASC S and A LDS, they could possibly be raised. Not always, but um you would just be looking at that as well and then you'll be looking at your bilirubin which will be raised as well and that would be probably indicative of chitti with cholecystitis tends to be a little bit more, tend to be a little bit more, um, normal or in normal range, but you would have your raised inflammatory markers, um, but very good to know in terms of if they were to give you, um, investigations in your OS station to be able to interpret that. So, moving on, um, in terms of management. So if the patient is not having any symptoms, you could just have um conservative management. So you don't really need to have any intervention. You could have um a cholecystectomy. If there are symptoms and complications of the gallstones with acute cholecystitis, you want to um admit your patient, you wanna make them know by mouth, give them IV fluids, um antibiotics and an NG tube. If they are vomiting, you would consider an E RCP. And this is because while an M RCP is good for imaging, um CP, you're able to visualize the biliary tree as well as remove any stones that may be obstructing. So it's kind of a two words with one stone and then you would do cholecystectomy within 72 hours of the acute admission, you wanna do it as quickly as possible because basically, the longer that you do leave it, the tissue becomes more friable. And in that case, sometimes they may choose to resolve the infection first. Um And so basically delay it for 6 to 8 weeks and then remove the gallbladder. If it's something that is bothering the patient quite often with acute cholangitis, it's emergency admission management of sepsis cause the patient is quite acutely unwell. You would do blood cultures patient will be put into HD U. Um You would consider an E RCP. If that is not possible, you can do um percutaneous transhepatic cholangiogram where you basically drain kind of all the pus and stuff from the gallbladder. So, moving on to diverticular disease. So, diverticulum is uh basi basically a hollow out pouching and it's quite a common structural abnormality in the intestine. Um It's mostly due to weakening of the um muscles in the large intestine, um basically called the tia coli because these tia coli, they basically form three strips in the intestine, but they don't cover the entire thing. And so the areas that are not covered by them tend to be quite susceptible to um forming outpouchings. And diverticulum, diverticulum tends to not really form in the rectum because it is um covered by this outer longitudinal muscle layer that surrounds the complete diameter. And the most common region for formation of diverticulum would be the sigmoid colon. Um And so you can have a congenital diverticulum which be, which would be your meckels, diverticulum or you can have an acquired diverticulum, which is probably more common. The concept, it's basically formed by consequences of like a refined diet, a diet with less fiber in it and combination of basically altered collagen structure with aging disorder motility, increased intraluminal pressure, um resulting in herniation of the bowel. So, some complications associated with it would be diverticulitis, abscess formation, peritonitis, hemorrhage, fistula formation and intestinal obstruction. Um Your patient basically with diverticulitis, your patient could present with um left elect fossa, tenderness, fever, diarrhea, nausea and vomiting, rectal bleeding, palpable, abdominal mass and raised inflammatory markers. Normally just with the diverticula itself, patient could present with left um abdominal left elect fossa pain or left lower quadrant pain and like change in bowel habits, things like that. Um So yeah, um the Henchy classification is normally used to classify diverticular disease. You probably won't be asked about this in exams, but it's just good to know. Um So yeah, in terms of investigation, it's normally diagnosed incidentally if a patient is getting a colonoscopy for something else. Um And in terms of um CT scans as well and then you manage it by first just trying to increase fiber in the diet, especially if it's not an acute presentation, you would give them um stimulant laxatives, sorry, you would avoid giving your patient stimulant laxatives cause that's gonna make things worse. Um And then you would give, you may offer the patient surgery if um they're having quite recurrent symptoms or they're having quite significant symptoms to remove the area that's most affected by the um diverticular disease. So, moving on, um we have acute diverticulitis, which is quite a common complication of diverticular disease. If it's uncomplicated, it can normally be me uh managed in primary care. So that will be giving oral antibiotics, analgesia, uh and clear liquids and you'll follow up with the patient within two days to make sure that they're doing all right. If there's severe pain and complications, then they will need to be placed nail by mouth given IV antibiotics, IV fluids, analgesia and to urgent surgery and possible complications would be perforation, peritonitis, peri diverticular abscess, a large hemorrhage, fistula or lisin obstruction. So that's just things to keep in mind. So next, we're gonna move on to intestinal obstruction. So this is just the pathophysiology of it. You can look at it in your own time. Um Because I think, um just in terms of, of, I think this is something that's quite high yield, not the pathophysiology, but the management of it and the differentiation of it. So, if we're looking at small bowel obstruction, it's very good to know the causes. So the three main causes would be adhesions, your most common cause hernias or strictures. Um in large bowel obstruction, it would be a tumor, volvulus or diverticular disease. The four cardinal features of small bowel obstruction would be absolute constipation. So this means no feces and no flat is as well, abdominal pain, abdominal distension and vomiting. Um And then in terms of your large obstruction, quite similar. So you'll have nausea and vomiting, absolute constipation, abdominal pain, distension and peritonism if there has been, um, a rupture. So, with investigations, you would choose, um, uh, abdominal X ray or a CT scan with your large bowel obstruction, abdominal x-ray, you would get an, er, XR, just to see if, um, for any bowel perforation, then you can see, um, free gas underneath your diaphragm. So then in terms of management of your small bowel obstruction, it's normally the drip and suck method. So, nil by mouth IV fluids, NG tube mostly will settle with conservative management like this, but sometimes you may need surgery and then with, um, the large bowel obstruction, nil by mouth IV fluids, NG tube with aspiration. And once again IV antibiotics if surgery is planned or you're suspec suspecting a perforation and most of the time surgery would be required. So with, um, I know x-rays was covered by my colleague under gi so I'm not gonna go too much into them, but I just want you guys to know the main differences between a small bowel and a large bowel obstruction. So with small bowel obstruction, um, you have the valvular convenes completely across the lumen and this kind of gives a stacked coin appearance and the bowel itself is located centrally on the X ray. Um I'm sure you would have heard of the 369 rule. So three cm for small bowel, six cm for the colon and nine cm for the cecum. Um, so that's also another way of differentiating between small bowel and large bowel obstruction and with large bowel obstruction, you have the host which extends not fully but halfway across and it's not centrally located. It's perfectly located. Um, another thing that's quite common is sorry. Another that's quite common is Volvulus. So sigmoid, volvulus has a coffee bean, ex, um, coffee bean, ex, uh appearance and it is the one that is more common and it's treated with rigid sigmoidoscopy and a rectal tube. Whereas um a cecal ovula is looks sort of like an embryo. It's less common, however, and is treated with right hemicolectomy. Um And basically valgus is breas twisting of the intestine around itself. Um So I don't know if there are many of you on the call itself, but we'll see how many answer. Um But basically, um 77 year old man has a one month history of dark red rectal bleeding, mixed with the stool, increased frequency of defecation. So, um hemoglobin is 100 and one MCV is 72 and fecal occult is positive. So, what is the most likely diagnosis? What is? Yeah, see. So, um yeah, that's right. So colorectal carcinoma because you're thinking your fecal is positive. He has a bunch of red flags and symptoms like his um rectal bleeding, um, increased frequency and basically change in bowel habit and patient is anemic as well. So you'd be most worried about um something sinister like colorectal carcinoma. So, um I think the red flag symptoms is covered ve very well in the gi lecture. So I didn't wanna go through that today, but um basically just in terms of management of colorectal carcinoma. So firstly, you wanna do your investigations. So that will be your urgent two week colonoscopy, ct colonography and you would do your carcinoembryonic antigen or your C ea antigen near a tumor marker. Um And I think this is something that has been assessed in an osc year three oscopy before. So it was a station on pr bleeding. So basically, what you would do is take a history of all your red flag symptoms and then they'll probably ask you how you manage the patient and it would be like a urgent two-week colonoscopy if it was a GP setting. Um So just in terms of the management surgical management of it, it would depend on the site of cancer itself. So if it's your cecum ascending or proximal trans colon, it'll be on the right side. So that's a right hemicolectomy. If it's a distal trans or descending colon, left hemicolectomy, sigmoid colon, high anterior resection, upper rectum, anterior resection, lower rectum is like an anti resection or a low t and the anal budge is a ap so abdominal perineal excision of the rectum and these are just pictures of um how it looks like. So you can look at that in your own time sometimes it's like a left helico hemicolectomy. Sometimes you do like an extended left hemicolectomy. So it just depends. But as long as you know, your main ones, you should be fine. Um, and then just risk factors for colorectal carcinoma would be family history of bowel cancer, the genes. So F AP and the HNPCC IBD, smoking and alcohol and obesity. So, moving on, I think stoma is one another thing that's quite, um, important just to know um could be asked in an OS Station, could also be asked in your MCQ S, but it's just to know the difference. So you have your ileostomies, you have your colostomies. So your ileostomy is located on the, mostly on the right hand side. Colostomies has a high variation, but most likely on your left hand. Um So your left leg fossa, um Ileostomies are spouted and that's because they produce um quite liquid content. And if that's quite close to the skin that's gonna irritate the skin around, it's gonna get infected quite a lot. So that's why they tend to be spouted. Whereas um colostomies tend to produce more um solid um content. So that's why it's flattened to the skin. And um yeah, in terms of content, Iost toy more liquid. Colostomy, more solid and that's just pictures of the types of stomas. So you can have an N stoma, you can have a loop stoma and a double barreled stoma and you can basically have Iost colostomy and urostomy is probably more urology related but still all very important to know. Um, another thing, lesser yield but um, bowel ischemia. Um So types include like meric ischemia or ischemic colitis. Um, your risk factors would be an increase in age atrial fibrillation, endocarditis, um, hypertension or um, diabetes, malignancy or just smoking. And that's basically sudden onset severe abdominal pain, pure bleeding, diarrhea, fever, lactic acidosis. Um And you would investigate this with act scans. Um And in terms of the difference between the two mesenteric ischemia is basically caused by an emboli. Um And so you're kind of something that will make the bells ring in your head. If you're taking a history of your examining a patient is they have a history of atrial fibrillation and treatment of it is urgent surgery because essentially your blood supply is cut off and you know, you wanna prevent um as much bowel ischemia as possible. So then in terms of ischemic colitis, it's most likely in the splenic flexure because this is known as your watershed region. And so the blood supply to this region is lesser. Um on the X ray, this can present with thumb, printing sign. Um Treatment is supportive. Some patients may need surgery. So, moving on. Um So you have a 78 year old woman developed a painful lump in her groin lump, is firm tender and located below and lateral lateral to the pubic T. So what is the diagnosis Um So I'll just move on. Um, so femoral hernia and so this is going into hernias. And I think um there are many different types of hernias, um, all important, but I think the most high you would probably be your inguinal and your femoral. Um And so it's just knowing the difference between the two. So inguinal is more common overall, but most of the patients affected will be male, femoral, more common in females. In terms of inguinal hernia, the location is quite important. So it's superior and medial to the pubic cubicle, whereas the femoral is inferior and lateral to the pubic cubicle. Um in terms of management, it um basically, the patient is sorry, I think this slide um something wrong in terms of this, but um inguinal hernia, um you can do a mesh repair depends if the patient is, I'll change this before I send it through, but you can do mesh repair. And if the patient is um quite unwell and if the hernia itself is strangulated or um obstructed, then that would indicate surgery. Whereas in terms of femoral hernia, you would um wanna do surgical repair almost immediately. And this is because of the high risk of str strangulation and in an emergency, a laparotomy may be considered. So with um yeah, sorry. Once again, the inguinal side, I don't know what happened to it, but I will, I will change it. Um So in terms of complications would be obstruction, strangulation of the hernia itself for inguinal and the same thing for femoral. Um And so that's why you wanna try and get it sorted as quickly as possible. So in terms of the inguinal hernia, you can have direct and indirect and I think this is something that's quite um important just to differentiate between, in terms of examination wise, probably won't give you this in a third ask you. But if you're on the wards and if the surgeon asks you, I guess it's good to know. So in terms of surgical anatomy, um your mid inguinal point is um your anterior superior IAC spine to your pubic synthesis. And the midpoint of the inguinal ligament is the anterior superior IAC spine to the pubic cubicle. And this is important because when you're trying to differentiate the hernias, so you would reduce the hernia and then you need to know where the deep inguinal ring is. So that's the ay to the pubicle. And so you try to occlude that ring, get the patient to cough. And if the hernia appears, it's a direct hernia and if the hernia does not reappear, it is an indirect hernia. And this is because with a direct hernia, it goes through the inguinal triangle into the inguinal canal and it's caused by weakness in the abdominal wall from age. Whereas with the indirect hernia, it's more so due to incomplete closure of the deep inguinal rib. And then I just have this picture here of other like hernias that um may occur in patients. Um And yeah. So perinatal conditions, um you can have hemorrhoids, anal fissures, anorectal abscess and just severe perianal pain. So, with hemorrhoids, you have painless bright red pr blood Pruit, thrombosis and prolapse, you'd manage that with um stool softeners, ice packs, local anesthetic or rubber band ligation, sclero therapy will be your next line and then your last line would be surgery of large and thrombosed. There is kind of grades of hemorrhoids are like 1234. And so that just did, the management will also depend on the grades and in terms of how much the patient's life has been affected by it, in terms of anal fissure, it's quite painful. Um And the pain is post defecation, it's kind of small, bright red, um P RPR bleed. And you manage this with a GTN ointment Botox in injection or a sphincterectomy is probably your last line. Um Inor recal abscess is quite severe pain. Um And because as an abscess, your patient will be systemically unwell. Um and it may resolve or on its own or it may develop into a fistula. Um And this could be like um through like with the urethra or fistula with the vagina itself. Um And so that can be quite distressing for patients. So, in terms of management, you would um consider exertion under anesthetic. Um, so drainage and IV antibiotics as well, and then with anal warts um mainly caused by HPV six and 11. And basically, it would be worried about your risk of anal carcinoma. Um So it's more common in immunosuppressed patients and your management would be surgical excision. And so a couple more questions. Um but basically this is looking at postoperative complications. So you have a woman develops paria reduced oxygen sats um two days after subtotal um gastrectomy, POSTOP pain control is difficult, um limited ability. So what do you think her most po likely POSTOP complication is so, OK, so we have e um so the answer is actually b so actis is something that's quite common um in terms of POSTOP pain um and POSTOP patients and this is just because, and we're gonna cover this. I have a slide on it in terms of the number of days. But um if you look at this, the patient, 37.8 is not exactly pyrexic, but her oxygen saturation is quite low. And this is because with postoperative pain, if it's not been controlled very well, um the patient will not breathe with as deeply as possible. And so her ventilation will be reduced. And so that causes ectasis. So that's something that you wanna keep in mind. So this is another one about POSTOP complications. So 48 year woman nausea and abdominal pain, two days after total abdominal hysterectomy, um she d she develops nausea and constant abdominal pain two days later. So pulse is 100 and 10 BP 80/40 abdomen distended and tender and urine output is 100 ml. So most important and most appropriate in the immediate management would be um intravenous uh naught 0.9 sodium chloride. Yeah. And so this is because um her urine output has been quite low and her BP is 80/40. So you wanna try and get that out first as well. So we're just gonna quickly talk about POSTOP complications. So this is just in terms of um what it can be the number of days after your um patients surgery. So the 1st and 2nd day after the surgery, you would think c so in terms of 3 to 5 days after you wanna think of water. So in terms of your urine, your bladder, so uti s urinary retention, things like that, 4 to 6 days after, if your patient presents, um depending on their presentation, most likely because of the immobilization, you would be worried about a VTE. So venous thromboembolism. So DVT possible pe so you'd be worried about those things 5 to 7 days after you'll be worried about wound infections, um or just in terms of your surgical site, things like that. And then if it's more than seven days, you might be wondering whether you know this is caused by the drug. So sometimes the anesthetics that I use sometimes fevers can be caused by, like, if a patient is on antibiotics and they happen to be like allergic to it. They may not have an anaphylactic reaction but they could just have, you know, high temperatures and things like that. So, you'd be, you'd be worried about that. So, I think that is my last slide. I'm just gonna quickly go through, um, possible coffee. Um, so not extensive. I do think with general surgery you're either, um doing a, doing a abdominal exam or a surgery, I'm sorry, or a history. Um, not a surgery, abdominal exam or history. Um I think it's quite rare that they would give anything else. Um But yeah, so basically be very slick with the abdominal exams, know how to differentiate um where the pain is. And um your patient may, your patient, your simulated patient may say that they're in pain in a certain region and that they are. Um I think the normal general rule of thumb according to Queen's feedback is to kind of avoid deep palpation in that region as well. Um just because you're causing your patient more discomfort. Um but this is a year three station in 2021 with a history of patient presenting with apr bleed. So you wanna take a history with your red flag symptoms and then you wanna rule out, you know, possible risk factors for CC as well and see how the patient fits into that and go from there. Year 3 22 22 was when I did my off and that was an ABDO exam. The differential diagnosis I think was appendicitis. I do think that was not really the focus of the station. It was more so because I think it was a COVID year. They were like the patient said, um I didn't wanna get a COVID test, but basically you had to be like, no, I'm sorry, you have to get a COVID test. Today. Year three, last year was an ABDO exam with um urinalysis. So I think that's probably testing two things in one station. And then our year five exam was an abdominal exam with um an interpretation of the pregnancy test. Um Other possible stations patient with a stoma. So be familiar with like a stoma examinations and looking at the content of the bag, looking at the stoma itself around the stoma, being able to identify what type of stoma it is. Um they could always get a patient with a stoma in a hernia examination. As I said, I don't think this is something that they would probably examine. You might be asked to do this on the wards, but I don't think this is, I don't, you never know with Queens, but I really don't think so. Um And then fluids are also something else that could be examined. I do think it's examined more. So in an acute medicine context where you wanna give a bolus of fluids but just be familiar with your normal saline, your heart solution and the use of that. Um So thank you so much and if you have any questions, feel free to ask me. But um I think Emer is next. Oh, so I'm just gonna be talking about wee bit on vascular. It's been a long night. So I'm gonna make this very brief. Um And I'm mainly focusing on ay tips cause I know you have done your um M CQ exam. So I kind of thought better to focus on oscopies for now. Um So if we can move to the next slide. Yeah, perfect. So basically, a big thing is to try and differentiate. Are they asking me to do an arterial exam or are they asking me to do a venous exam? So in terms of what you cover in both, if, when you're obviously looking at the legs, you want to get them to stand. Um So this exam has to be done standing up and you're looking for any signs of edema, you wanna look at the nails for any fungal infection or any other signs of infection. Uh And then you're looking for any ulcers, always make sure to be shown to look in between the toes and get the foot up and look at the bottom of the sole of the foot because that's where most of the ulcers are um feel the temperature of the feet. And the one that I always forget is the cap refill time on both the toes. Um And then you, you will remember to do your pulses cause it's probably the main part of, of the examination and then just distinguishing between arterial and venous. Then so with arterial, you're looking, the skin will be shiny, they'll have loss of hair, they'll have the atrophy blanch. And then if you run out of things and you're like, oh, I can't remember what else to do here, go through your six ps. So pain will just touch it. And is it painful? Um Pulseless, you'll do that when you're doing your pulses, uh partly cold, you'll do that in your temperature and paraestesia. So you could get a check if they're numb in the feet. Um and p and pulseless, Pressly cold pallor. So that's the looking to see if it's pale or any difference in, in the color. Um And there's one more I can't, I can't remember. But if you just go through those, then you will have covered most of the things that you need to, you need to distinguish. So there is just I'm saying that in arterial disease because the blood isn't getting to the feet, the feet will be cold. Whereas venous insufficiency, the blood isn't getting away from the feet. So the feet will be really warm. And then the special test for your arterial disease is your Buerger's angle. So you just lift the leg up until it changes color, but realistically, they probably won't ask you to do the special test for either of them because they're not really used, um, in this day and age, I've never seen them used apart from the A BPI. Um, but that's a bit specific. Um, and they wouldn't ask you to do that in an AK, but those are the special tests if they do ask, you have an idea of what they are. So the burgers is just lifting the leg up until um the blood drains and that's your burgers angle. And then with the Trendelenburg and the tourniquet test, they're just the same test. You're trying, you're either holding with your hands or you're turning with a tourniquet. That's the difference in the two. And you're just seeing at what point does the blood not return down the legs that you find your, you find the area? At what point in the leg does the um she arise really? So then with venous insufficiency, you've kind of got, I kind of group it the top three together because you have your hemosiderin deposits. So that's where the blood is like leaking out into the surrounding tissue. And that irritates the, that irritates the tissue. So it becomes really itchy. Uh So you get your venous eczema and then that causes an inflammatory response. So the skin all tightens up. So you get these wee skinny legs, but then they really become very large because they're so full of blood above it. Um Like people can also have um reticular and thread veins. So you can always comment on that. Nearly everyone will have, will have those. So that's an easy thing to comment on. And then the big thing that you don't wanna miss in a venous problem is if they have a DVT. So, uh that's if it's hot, if it's dilated, if it's painful. Um So those are big things that you want to rule out. OK? And then the next slide. Perfect. So that's that leg that I'm talking about. So the skinny ankle and then I see how the leg is all uh eczematous and um you can see the brown deposits at the top there. Um I'm not sure hemosiderin deposits. So to treat this, first of all, you need to um do an A BPI cause you need to make sure that before you're gonna give the person compression stockings that they have adequate blood supply to the foot because if they don't, then you're gonna compress the, the leg even more and cut off even more of the blood supply. So just make sure that you've, that you say that you're gonna check the blood, the A BPI and make sure that the blood supply and the use the Doppler, make sure that their pulses are all OK to the feet before. But the treatment is compression Stockings lifestyle or your big two big ones. And then sometimes they'll do sclerotherapy and they might do laser and very rarely will they do surgery. It's just not really done. It's mainly compression stockings. Um, yep. Mm. If we go to the next one, perfect. So then, uh, your acute limb ischemia again, is your six ps just run through them. Um, the causes of these are, there's three real causes. So it could either be a thrombosis or it could be an embolism which is basically a clot from somewhere else in the body. Or it could be a dissection higher up which is cutting off the blood supply. So if the arterial wall separates, then the blood can't pass. So you could get an uh acute limb ischemia. So that's really your three causes. Um And if you do a Doppler, there will be no blood flow. Um For this, we had this, this came up in our M CQ. And um there's two options most of the time they'll do a thrombectomy and or else they'll do open surgery. It kind of depends on the anatomical location of, of um where the clot is and if you, if you can get to it or not, so then just in terms of the progression. So se these different terminologies out in your head cause I find them a bit confusing. So, intermittent claudication, the pain comes and goes. So you, you all know what that is. It's like when they're walking, they get pain, when they stop and rest it gets better. So everyone knows what that is and everyone kinda knows what acute limb ischemia is. Uh it's kind of the ones in the middle. So, chronic limb ischemia is basically intermittent claudication, which doesn't improve with rest. And then critical limb ischemia is if we don't intervene, it's, they basically come under the same umbrella. But with the critical one, if you don't intervene, they will lose the leg basically. Um So that's just the progression you start with intermittent claudication and you can end up with acute limb ischemia. But often if you have the acute limb ischemia, it's because of one of those three things. So it comes on quite acutely as it's, as it says on the 10. Yup. Perfect. And then uh the, the other thing that they really like to test on is the difference between a venous and an arterial ulcer. So just know where they are. Um There's different tables that you can look at. They'll be in all the ACY books. Um But basically they have different anatomical locations. So the venous one is in that inner aspect of the ankle and foot. Um Whereas the arterial one is at the bases and then the neuropathic ones also kind of come under here, but they're not vascular technically. Um So the neuropathic ones will be at pressure points. Um But the arterial ones are usually at the ends of the toes, you'll see like the toes falling off. It's at the extremities and that's where like their, the ends of their toes start to go black and stuff. Um, with the venous ones, they're painless as well. Whereas with arterial it, it will be very painful. So even with nothing else, those kind of give it away, um, the venous one is more flush with the skin as well, whereas the arterial one kind of has more punched out looking. Um, but usually with an M CQ with an M CQ or OS, I suppose you can kind of tell by whether it's painful or painless. And, um, where it is really the neuropathic ones, they will generally be in a patient with diabetes because of the peripheral neuropathy. Um, and then we've kind of already went through how to treat, how to treat them. Um, yeah. So then, uh, I think this might be the last thing I'm talking about but the abdominal aortic aneurysm, um, know the screening for it. It's once they get screened once when they're over 65 and if they're a man, um, then the only other numbers that you need to remember is 4.5 to 5.4. Because if you know that, then, well, you also need to know that less than three is normal. But if you know, then, then the middle numbers kind of makes sense because anything between three and 4.5 you screen for yearly, between 4.5 and 5.4 which is our important numbers to remember cause they're the middle bracket. That's, um, you need to screen for that every three months and then if it's bigger than that, then you need to repair it. The other criteria for reparil is if it's growing more than one centimeter a year and just have a wee look at the D VLA rules, they wouldn't ask you that in an ACY. But um, they could in M CQ and just maybe to be aware that there are D VLA rules and to just let the patient know that they might need to let their um, the D VL I know would be, would be good. The big giveaway is that the pain radiates to the back. There are a few um pathologies that radiate to the back of pancreatitis, but there's not that many and usually when, when it says that this should definitely be one of your differentials. Um It is a surgical emergency. So, um you need to recognize it and act on it. So when people are feeling for it, uh well, the feedback to us was that some people are feeling below the umbilicus. And if you think of your, your aorta comes down and it splits above the belly button. So if you're feeling for an abdominal aortic aneurysm below that level, then then you're not gonna feel anything because that's not where the abdominal aorta is. So you need to make sure you're above the belly button. And when you're putting your hands in like that, to feel that it expands on a mass. And if you can feel one which they're not gonna have a patient with one. But if you can and you have to feel it both, both this way and this way and then that can be repaired openly or laparoscopically. Um, so just be aware, but, um, usually you wouldn't send them for act, if, if they're um hemodynamically unstable, you're gonna send them directly. First thing you're gonna do is you're gonna call vascular and get them basically on, on the table immediately. Yeah, I think that might be it. So if anyone has any questions, you can let me know um or if you have questions now, you can just shout out and we'd really appreciate if you filled in the feedback.