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Hello. Hello. Um, thank you for joining us. Um, so yes, so today we're doing a session on plastic surgery. So I hope everyone's day has been going well. Um, there's only, there's only a few people. Um, so I might just give it a minute and see if there's anyone else that's going to come along. But don't worry, I wasn't expecting as big a turnout as there is for over events. Um, so yeah, just give it a minute, but we can start and people can join as we go along if not. Um, yeah, and so yeah, so today, um, so for plastic surgery, um, it seems quite and slide across so it can seem quite a rogue thing because obviously there is no plastic surgery section on past med. I'm pretty, I don't think there is one inquires med doesn't really get covered as part of like medical curriculum, but it does cover a lot of, a lot of conditions and there's a lot of overlap with other conditions. Um, so you, you do, you will come across plastic surgery knowledge but in your head, it's probably filed under dermatology or filed under orthopedics or under E N T for head and neck stuff. Um So yeah. All right, we will, we'll make a start, we'll make a start. Um So yeah, so today's session is just gonna be on skin cancers and burns. Um So the first part of it is just on skin cancers and the second part is just on burns. Um If you've got any questions, as always, please pop them in the chat that will go along. Um But yeah, it will all be done on polls. So I'm not going to pick anyone out for anything. So don't worry, don't worry about that. Um So yeah, we'll just get started with the first question if you don't know. Don't worry, just have a guess. So a few people have just joined at the moment. So there's about 40 seconds left for this question. Um So feel free to have a guess 10 seconds, right? We'll leave it there for the people that voted. It was a clean sweep. So it sounds like, you know, stuff. Um But yeah, this was just as you would expect the classic E C C. Um So yeah, this is sort of, there's no picture for it, but this is a classic example of what you would expect for A B C C. So it's an elderly person. There's a lesion on the face as a head and neck is sort of classic sun exposure sites for A B C C slowly progressing um around lesion raised, it's got central depression and the edges are rolled okay. And that is the classic thing is sort of pearly rolled edges. Um And it contains some telangiectasia around which is like the spider nieve, I kind of thing. Um So, yeah, so I'll just go back. So the other conditions. So if you were thinking of anything else, don't worry, we will go through it. So malignant melanoma, sec actinic keratosis will go through all of these in a moment. Molluscum contagiosum is the only one that we're not going to go through today because it's more um slash Pedes thing. So briefly, just to explain that if you were thinking of that or if you didn't know what it was, so that would present very, very similarly in terms of it's a similar sized lesion, it would also be round when it looks like this. It also be round, raised, flesh colored pearly edges and the difference is that one is an infectious condition. So it comes on all of a sudden and, and two, it comes on in clusters. So like you can see in the picture here, you get loads of them at once as opposed to just one. Um And finally, it's more of a, you see it more in young people. So peak incidence is 124 years old, so unlikely to be this in this case fine. So yeah, so brief slide on BCC. So as you can see from these images. This is like a classic BCC with the pearly rolled edges here um and the central ulceration. So you first start off with these pearly white rolled edges and then as it progresses, that's when you get this ulcerations, as you can see here in the middle of the lesion and the slow growing, mainly seen in elderly people and they're in sun exposed areas. So it's sort of head and neck really for them. It's one of the only cancers that you just do a routine referral if you suspect it, you know, it doesn't have to be under a two week wait. And the reason for that is because it pretty much doesn't metastasize. Um So you're not worried about it spreading. Um And it's just managed surgically by excision um for the most part. So yeah, next question, 15 seconds left. If anyone wants to go, I guess in bit mixed this time, a few, correct answers a few, few wrong ones, but don't worry. Right. So this one, well, the uh the other guy is seborrheic keratosis, which is like your classic old mole. Um Now it is a bit confusing this one and the main one for this that people will might have difficulties with is distinguishing this from a melanoma. Okay. Um I've seen that someone has put actinic keratosis. Um I'll ignore it for this question in terms of I won't explain it into too much depth because it does come up in a moment. So I can explain what that is in more detail in a moment. Um But if we go through it, so several keratosis is very, very common. Most people will have a sub K a seborrheic keratosis and it's normally on the face and on the torso. Um And they have, you'll see it written down in textbooks as a classic stuck on appearance and that's what this kind of looks like because if it's just stuck onto the skin, um, now it's unusual for this one, most people don't have them this large. Okay. Um But so that's why there's this confusion of whether it's a Melanoma. So why is it not a Melanoma? Um So obviously there's a history and it's growing slowly so it could be a Melanoma. But the main things that you use to determine how likely it is to be a Melanoma other than biopsying, it is major and minor criteria. So there's free major diagnostic criterias. So that's a change in the size of the lesion, a change in the shape of the lesion and a change in the color of the lesion. Those are the three major ones and the minor ones. Um if the diameters more than seven millimeters, if there's inflammation, if there's bruising or bleeding of the lesion, and if there's altered sensation around the lesion and so you can see from the history here, um, it's gotten bigger. So change in size, the diameter is probably more than likely more than seven millimeters. Other than that, there's nothing else here in reality, you would probably refer it and you would want to biopsy it just to make sure. Um Or that's what I would do as someone about stars and effort one, I think when you get to a senior level of that would be quite commonly identified as a sub K quite quickly. Um But yeah, the basal cell carcinoma. So we know it's not that because we've been through what that looks like. And for actinic keratosis and sec will explain that in a moment fine. Next question, 10 seconds left, right. We'll leave it there. Um So, yeah, so, well, then I think everyone that voted got this one. So superficial spreading melanoma is what it was. Um So I'll stay on this one. Um So, yeah, so this is from the history. It's a classical description of what you would expect from a Melanoma. So, like I was saying on that previous slide, the major and the minor diagnostic criteria. So here we've got change in size, we've got a change in color um and the shape of it. Um it's asymmetrical, pigmented lesion. So it doesn't specifically say that's changed in shape but evolving lesion, asymmetrical, it could guess that this is changing in um in shape. Yeah. And in addition, yeah, like we said, changing cord there. Um In addition to that, we also have risk factors mentioned So using the sun beds is one of the risk factors. I'll go through all the risk factors in a moment, but that's, that's one of the risk factors. And then Fitzpatrick skin type two is another risk factor. So I'll ask it in the chat. Does anyone know what Fitzpatrick's get? Uh, it's a difficult question to ask. Um, I'll show you the slight, I'll show you this that, but Fitzpatrick Scale, um, some of you might have heard of it. Some of you might not um what it is. It's a way of classifying skin colors. And the reason that we do it is because you, we know that if you're type one or type two, then you're much more likely to get a Melanoma then if you're type five or type six. Um So I'll leave this up for a second, but the difference is it that you can remember it by is how easy you burn and how easy you can. So type one always burns, never tans on the other side. It's pretty much never burns or tans very easily. Um That's, that's the other side of the spectrum. Um So going back to this one there. So we know it's not BCC from the description. We know it's not, well, actinic keratosis, we'll discuss that in a moment. Um Melon melon learned know citic nevus is like a mole with it changing being asymmetrical, not thinking that this is more worried that it's something more significant. And then again, I've got a question coming up in a moment on the types of Melanoma, how to distinguish between the two here. Um, generally for this question, though, just think superficial spreading is the most common. Um, so for general MCQ knowledge, if you don't know, that's fine, just guess for the most common and that's superficial spreading. But we have got a question coming up at the big table, outlining the differences. So we'll go through that next second, next question, 15 seconds left, right? Whether there's a couple of correct ones. Um So well done for those that got it. It is refer under a two week, wait for this one. And so hopefully you can sort of see from this image. This is what when, when you think of Melanoma, this is sort of a classic image that comes to a lot of people's mind. So we've got an asymmetrical lesion here. Um There's a history of um so yeah, asymmetrical quite large lesion, multiple colors here with it. Um Now, one thing that might throw people off is it says here, reports no change in any of his moles, no bleeding, no itch. So no change would rule out a lot of the major diagnostic criteria. However, is a sneaky one for this, for an MCQ style in someone that's got 2025 moles. You've always got to take it with a pinch of salt when they say no change because it's very difficult to accurate, accurately, keep track of your, all your moles. Um If you've got so many, so anything that you think is suspicious of a Melanoma and this does have faxes, which would make it likely to be a Melanoma or certainly raise suspicion of it. You need to put on a two week wait scheme, a two week wait, pathway, two week wait. Um Yeah, pathway and to rule out an adenoma. Um And the reason that Melanoma goes on a two week way as opposed to B C C is because it metastasizes quite early and those metastasized, most metastases and can be fatal. Okay. So that's why you would do it there. Now, some people put photo mapping. So photo mapping is a completely valid thing and that is what you would do in this individual considering they've got 2025 moles. However, you wouldn't do it for this specific lesion because you'd be worried about this being a Melanoma. You should do photo mapping just in someone that's got this many moles in general so that you can keep an accurate track of what's going on. Okay. Um And that's sort of the same for these, these bottom two options here is valid to give advice about some protection, valid to take a photo for the record so that you can review it later on. But you need to put this person under a two week away because you're suspicious of Melanoma fine next question. Oh. Um, yeah, the question. Um, I'll just go back for a second question about the cough. I don't think that is relevant but it could be, um, it definitely could be, you could be thinking, has it metastasized? Is it there in the lungs? Something like that as far as I know, it doesn't metastasize to the lungs that quickly. Um, but it definitely could be. Um, I'm not sure, I'm not sure how much that sentence ways into your thoughts though. Um, but yeah, hopefully that makes sense. All right. 20 seconds. Just have a guess if you don't know. Don't worry. Right. So for this one, a lot of people got this one, um, depth depth for the Melanoma. Okay. So that is the key thing for Melanoma. Um, in terms of how this very it is just based off of the depth. Okay. Um, now you don't need to know this form, seek us. It's quite niche other than depth. If you just leave your knowledge at depth of the Melanoma, that's completely fine for M C Q s. Um, for those, I'm assuming if you joined a plastic session, you might have some sort of interest in doing plastics. Um, specifically, it's Breslow fitness is the term that they use. And that's just how deep does the Melanoma go into the skin. Um, so you can see here, obviously, the deeper it goes, it does have a significant impact on your survival. Rates. Um and they use the depth to determine the tumor score in the TNM scale. A TNM system for Melanoma cancers. So, T one cancer is a stage one here and then A T four is stage four here. So you don't have to know this firm CQ is unlikely to come up. Other than the fact that depth is the prognostic um tool that's used to determine melanoma severity and prognosis. Right. Next question, all of these are on Melanoma so far, but I promise you, we will change subjects soon. Yeah, 10 seconds, right. Let's go with this one. So well done to those that got to. So this one isn't superficial spreading um normally is. So this one is Akra, well, Lynn Tigers, Melanoma, um and I've got a table coming up explaining all the different features of each one. So don't worry. Um Don't worry if you, if you don't know it, um it's not crucial that you know this for your exams, it's probably fine. But again, this is just uh the next step of knowledge if you wanted to, if you wanted to learn it. Um So for the table, so these on the four top hair are the foremost four types of Melanoma. Um The big ones, it's a superficial spreading. You can see counter 70% of cases. That's the main one. Don't worry if you don't, if you don't want to commit this two knowledge, which is completely fair enough just get superficial spreading for your M C Q s and more than likely it will be fine in a question like this though. It's testing specifically and it's listed all of these. So it's expected to be a little bit more niche, the knowledge that they're testing. So the way that you can test that you can tell each one apart. So the way I remember superficial spreading, that's the most common young people, sort of sun exposed areas, specifically those sort of back, chest arms. And that's just the classic image like we showed before about that more nodular, second, most common, but it's the most aggressive. It's the most severe form of Melanoma. Um And the way you remember is nodule, it is a nodule that is literally a a lump on the skin as opposed to something that's flush with the skin and it oozes and it can bleed. Ok. Lentigo malignant to this is a rarer one, but this is generally seen in older people with chronically some exposed skin. So the way it comes from the word Lento, which means slow, okay, so slow, chronic exposure that just builds up and it's very similar to superficial spreading just less common. But it's only occurring in older people because it takes so long for that exposure to kick into causing this. And ac rel um Melanoma, the answer for this question that affects, that's quite an easy one to remember because it's one that affects nails, palms or soles of the feet and the way that you can remember that is so acro comes from the same word that acromegaly is used for acro just means limbs, distal part limbs, which is the same as acromegaly with big hands, big feet. And so that's how you remember it's on the nails, palms and soles. Generally it's in people with darker skin. Okay. So if we go back to this question here, knowing what we know. Now, from that table, um You can see that she's got a pigmented, pigmented skin on her toe. Okay. She's Afro Caribbean, so got darker skin. Um And she's got pigmentation on the nail bed um affecting the great toe, a big toe. So those are all signs of go back of mackerel uh Melanoma here. Now, specifically for those that you want to know, you might already know it. Do you know what actually I'll ask? Do you know what this sign is called in the toe? I'll give it a second. See if anyone knows. Don't worry if not, uh I'll move on. Um It's called Hodgkinson sign. Okay. So there, there are other Hodgkinson signs, but that is what it is here. It's sort of the Melanoma, the black nail fold in fox black toenail. Um And that is a sign of actual Melanoma. So, yeah, so Hodgkinson signs up again. It's niche knowledge. So don't worry about. So, yeah, so that's the end of Melanoma. So just a summary. So these are sort of some classic images of it. Um Again, it's common on sun exposed areas but can involve the sort of chest and the back as opposed to be CCS. Um They're the most likely form of skin cancer to metastasize. So you're the most concerned when you see a Melanoma, as opposed to any other skin cancer, there's the major and minor criteria for it and I'll send, we'll send out all these slides at the end and it's got a list on from the previous slides. Um, and the different types of Melanoma again, which is included in the table in terms of management, it always needs to be put on a two week wait referral and it's generally managed surgically and you can also give immunotherapy as well for it depending on the stage in terms of risk factors. So these are risk factors for Melanoma, but specifically, just generally for skin skin cancers as well. So these are important questions to ask in a Noski. Um If you get skin skin cancer history, um, see one of, first of all established, what they're UV exposure is. So, do they have any hobbies that mean they're outside in the sun a lot such as gardening or rock climbing or playing football or whatever? Where do they work? And what do they work as? So are they involved in the army or the Navy, army or the Air Force? And have they been traveling across the world. Have they lived abroad previously? Um, do they work as a, as a gardener? And they're outside a lot and things like that? And also, have they ever been on Sunday yet? And if they have, how long have they been on them for? And are they immuno suppressed? Have they had bad burns as a child? So, that's sunburns. Do they remember being burned quite badly when they were younger? Have they got a personal history of skin cancer? Is there a family history of skin cancer? And then are they quite fair skinned? So quite pale? Like like these, these, these, these patient's here? Um So those are the big risk factors to look out for fine. So next question, if anyone's got any questions, by the way about anything that we're saying, I'm saying, please just pop them in the chat. Um I'm having to explain anything 15 seconds. All right, there we go. Um So I'm gonna look on the slides. So hold on to those of you got it. And as promised, we are coming to it. So, actinic keratosis is what this is. Um So again, actinic keratosis probably unlikely to be directly tested in your exams, but it will always be, it will very likely be listed as a differential. And one of the options um for, for the questions that you get asked, especially related to squamous cell carcinoma, which we'll get into in a moment. Um So what what it is. So it's a pre cancerous condition, okay. And, and it comes from chronic sun exposure. And I hope that the image here is a pit poor lighting, but I hope you can appreciate there's sort of multiple red patches all over the forehead here and on those patches, you've got little scabs or crusting and little lesions everywhere. And that is actinic keratosis. So it's sort of covering quite a big area there. And as you'd expect with it been sonic relates on exposure, it is often on the top of the head for men, um can be on the face, it could be on the arms anywhere that's been exposed to the sun. Um Now, like I said, it's a pre cancerous condition. It's because it's specifically pre cancerous for squamous cell carcinoma. Um But because it is just linked with chronic sun exposure, it's you, you can't rule, it doesn't mean that it couldn't be a B C C that's there or a Melanoma that's also there just because of the sun exposure. Now, the thing that you need to always make sure that you rule out with actinic keratosis is have a look at each lesion specifically and make sure that any of these isn't an sec in particular. Um So, yeah, so it's not BCC because being from BC, it doesn't really look like that SCC will go through in a moment. Uh several keratosis again, it doesn't look like any classical mole was stuck on a parent here. Uh several dermatitis. So no one put that so well well done. No one fell into that trap, but it could, it sounds similar from the description. It doesn't look like this on the description of Seborrheic dermatitis. You've got a red patch with a scab in and crusting around it. Now, it's commonly sort of people think of it as just dandruff. Um So it could be this, but generally you would expect around the hairline and you would also expect it on the eyebrows or around facial hair and, and there's no evidence of it from here. Um So yeah, next question. 10 seconds. All right. There we go. So world and everyone seems to get this one. Um So yeah, Bowen's disease is what this is. Um if you haven't had a bones disease, don't worry, it's fine. Um But bones disease similar to actinic keratosis is also a precursor to squamous cell carcinoma now, and actinic keratosis is a pre cancerous condition. Whereas Bowen's disease is essentially squamous cell carcinoma in situ. So it is essentially sec but it's just not going to spread yet. It's not penetrate deep enough at this point. So if we go through the differentials, so basil cell carcinoma, we know what that looks like. This doesn't look like that. Um Exact same thing for seborrheic keratosis. So we know it's not those two. Uh So tinea capo Rhys otherwise known as like a ringworm infection. So that's what this one looks. That is this here. So you could almost make a case that it's similar to that. If you look around the edges here, there is maybe a case that you could say it looks like that sort of worm at the edge. However, it wouldn't explain this sort of these alterative parts of the lesion. So it's less likely to be that. Um And the nummularium Isma. So I didn't, I still don't really know what nummular eczema means, but it's just a type of eczema basically. And it normally looks like these with these little patches and, and again, you wouldn't expect these ulcerated parts. So that's why it's not that. Um, so, yeah, so Bowen's disease, if you don't know what it is, don't worry about it. The only, the only reason I mention it is because it's essentially like a pre cancerous or, or is an sec in situ. So Bowen's disease, if you leave it, it will. There's a risk that that progresses onto squamous cell carcinoma. It's about 5 to 10% risk for it. It's a small ish but still relatively significant. Fine. I think this is our last question on skin cancers. Yeah. Yeah. That's right. Sharman. Yeah. Okay. That's the time up there. So, this one, you might have been able to guess what it is just by nature for the fact that we've not had an answer. That is this yet. But it is a squamous cell carcinoma. Um So yeah, so as it says in the description there, so there were a few people that put B C C and I can understand why. Obviously it's an elderly person um chronic like long term they've had, it's been slowly getting larger. There is some telangiectasia around. But the key thing here, the way that I would approach this is it just doesn't really look like a B C C. Okay. So there isn't that raised, rolled edges, pearly edges here and there isn't a central depression within that, within the raised borders. Um So that is the way it is. It's a bit of a sec is a bit of a weird weird one for me in that B C C has classic descriptive picture of it. The same thing goes for a Melanoma and then an S C C is kind of just vague in the middle and you know, something's wrong, but you can't say for certain that it's an sec, it just looks suspicious. Um Now, the reason it's not actinic keratosis is we've seen that's more of a patches of red with scabbing on, but you wouldn't expect this degree of, of ulceration. Their a kerat oh Can foma um that is often um difficult to distinguish between an sec. However, it's normally like a volcano type lesion. And so if you google an image of that, it's a raised volcano and they regress by themselves, but they're often excised um and biopsy just to make sure it's not an sec. So BCC, the main thing I'd say here is it's not got the text book, classic pearly rolled edges. Um And it's quite large. Um Which is why wouldn't think it's A B C C. Um And we know what Melanoma looks like. This doesn't fit that picture. So just general quick slide on squamous cell carcinoma. So, like I said before, there isn't a sort of textbook characteristic um definition of what an sec would look like normally. But you can see it's just an ulcerated, generally ulcerated, but it's varies from individual to individual. But again, it affects an exposed areas. So that was on the cheek and there's one on the lip, on the ear and again, another one on the cheek. Um so it can grow slowly, but it can also grow quite quickly as well. No classical description there is can be more common to be bleeding. Um And it can metastasize it metastasized is more often than be CCS uh but still quite rare. It does metastasize um compared to a Melanoma at least. Um So yeah, fine. Last last question on skin slash skin cancer, I promise 10 seconds, right? A bit more mixed from the answers. Few people got it right down. So this one is a dermatofibroma. Um So don't worry too much about tomato fibromas similarly to before it's probably not going to be tested when they're wanting this answer, but you might have seen from doing pass med that it does often come up as one of the options that you can pick. And so I just wanted to put this slide in. They're just so you knew what it was and it wasn't this vague thing that you, you kind of new. Um So this is what amount of fibroma looks like generally. So you can see from, from the description here, sort of a raised, a raised lump which is quite firm. Uh mon tender. So that, that's what it looks like. And when they say positive retraction sign, this is what it's like. So if you pinch the skin as you go down, um and sort of flattens out and that is sort of one of the signs of a dermatofibroma. Um So generally a her phone in drink, shaves their legs once a week and occasionally get scrapes. So that's we've got source of where it's come from and, and it fits the description. So a solitary firm papule that dimples on pitching on pinching be CCS. Um So she's a bit too young, she's only 26 it's on her leg, on a calf. You wouldn't really expect her that it's more head and neck. Um It doesn't fit the classical description of A B C C as well. Um Similar sort of things for a Melanoma again, so you can get it on, on your legs. Um Melanomas more so than be CCS. But again, bit less likely she's not got, um, risk factors really for Melanoma. Yes, it says she doesn't use sunscreen, but she doesn't go out in the sun that long anyway. Um, and the Melanoma you would expect that it could potentially bleed or bruise, which isn't the case here. Lipomas. So, lipoma's generally grow beneath the skin. So you wouldn't have a nodule outside of the skin. Um, and sebaceous cyst. So a few people put this the main way to distinguish it is that it doesn't dimple when pinched. Okay. It stay as a lump even when pinching the skin nearby. So, yes. So hopefully that makes sense fine. So we're onto the burns questions now. Um That's a good question. I believe he can just leave them by themselves. Well, I'll make a look man to look it up if that's okay. So, thank you. I think you just leave dermatofibroma is alone because I think I've seen them in like GPS and then, um, then GPS, they tend to just leave it alone unless it's really bothering them. So, yeah, I think you just leave it alone. Okay. 15 seconds. Oops. There we go. Right. So even a bit more mixed here, but some people did get the right one. So the colon if the test is the correct answer for this one. Um So it's a bit strange. So you've gotta, I almost fell into the trap when, when answering this, but you've got any acute situation. You've always got to try and run through it with an A T E approach, as I'm sure they've tried drilling into your med school so far. Um, so looking specifically at the airways here, so you can see from the history, there is signs that the airway might be damaged. So there's sort and blistering around the mouth and the swelling of the oropharynx. So you're already alarmed that something could be going on on the airways, specifically for burns and burns from house fires. You've got to worry about inhalation of, of gasses and of, of all sorts and for inhalations of things. So it goes all throughout the lungs. It's not confined to just the upper airway. So you can't really use simple airway junks there. Um So for this patient, when you're thinking, seeing the swelling, you're seeing the stuff around the mouth. Um Seeing low sats, you've got to be worried that this airway isn't patent. It's always best to call an anaesthetist before the airway closes than then waiting for it to close and then call him. Okay. So, always address a of the A two we first, which is the airway and there's just a big risk that the airway is going to collapse soon. Um The other options are all valid. They're all correct. It's just you wouldn't do them first. So if you look at the breathing, if you go down, so once you've done the airways, you then go on to breathing, so delivering oxygen again, completely valid considering he's got low sats, um, no signs of COPD. And again, because he's got the low sats, you could do an A B G to, to find out a bit more about that fluids. You would definitely want to give fluids. But again, it just isn't as crucial the need for at the, at the moment. And morphine again, you can give for the pain and it would be a good option to give for the pain, but you would be doing that after you sort everything else out. So hopefully that makes sense. Um Fine next question, a couple of early answers coming in. Yeah, 15 seconds. One of the final guess right. There we go, we go through it. So a lot of people got this one, um is one of those that if you know it, you know it straight away and if you don't, then it's, then you don't, hopefully you will know now. So yeah, so it's the Parkland formula. Um and that's the formula you use to determine how many fluids, how much fluids to give in someone that's had a burn. Um So if we go through what each of them are, so the Parkland formula, I will give you a warning. I've got a question coming up using this formula generally though. You do not need to know the formula as if you know the name of it, then that is more than enough and generally firm. See queues what it is though, it's 4 mL times the total burn surface area. So in this case, 40% times the body weight, which it doesn't say in this case. So for example, it would be four times 40. Okay. So you just use the base number of the percentage you don't do 400.4 or anything like that. And then I've guessed 80 kg and specifically, you give half of that within the first eight hours and then you give the rest of it in the following 16 hours. So you want all of that fluid to go in within 24 hours, but you need to make sure you, you're correct it quite quick. Um So if we go through the ones, so the Apache to score, I haven't heard of this really, but that's used to estimate mortality rate in intensive care. Um Lights criteria. So that's used to determine whether a pleural effusion is translated or executive. And when it's in the middle, um Cockcroft gold formula, um that's a method to estimate the mail a filtration, right? So calculate E G F R essentially. And the Well school, you can use that to assess the risk of it being a DVT or PE. Um So yeah, so hopefully that makes sense. Um So as long as if you know, if you already know the parking formula, it might be a nice idea. To, to learn what it is, to learn the formula. If you don't know about it, just remember the name and that would be more than enough, I would imagine. Um, but yeah, next question. Thank you. Five seconds. Right. So this one has a few people have got a few might tricked a few people. Um, so it's the London and Browder chart. So I'll go through what all of these ones are in a moment, but just to explain briefly what the London Browder chart is. Is this. Um So it's the, the best way to West to calculate percentage of burns. So you just look at each body part and, and if there's a burn there, then you account for that percentage. So you've got to make sure you account for both anteriorly and posteriorly. Um And you'll see, it says A for the head and then B and C for the lower limbs and that the percentage for that will vary depending on how old the individual is because obviously those proportions change as you get older. Um I if you could commit, if you could commit that to your memory's a question that is very, very impressive. I cannot. Um And I never tried to be honest. Um So the main thing is just to remember that London and Browder chart is the best way to calculate percentages of a body of a burn. Um And you can always just Google this image as and when you need it. Um So going through the organs, so low GMA, so that assesses visual acuity. So he used money in ophthalmology. Um The Rosier score stands for recognition of stroke in the emergency room. So as the name suggests, it's a way, it's a clinical way of screening for a stroke Snell in again, that's visual acuity and the rule of nines. So the rule of nines is used to calculate burn percentages. Um But it's a more, it's a quick, is used for quick assessments at the end of the bed. Um So I'll show you what that is in a second. But you, you may come across if you've got a plastics placement, you may come across people using it, but it's not, it's not the one that you should use when trying to get a definitive percentage. Um So the rule of nines, it's, it's very similar to before. It's just quite a bit easier to learn, obviously because everything comes to nine. Um So you can remember it much more quick, quickly. Um But yeah, so if you get asked about a question though and they've got both of the options, then just pick the London Browder chat. Fine. We're getting right there and yeah, okay. 20 seconds. I'm impressed there's quite a lot of people getting it right. There we go. So if we go through this, we'll go through it well done to the people that got it very impressive. So it's 3.5 liters in this case. So we'll go through, we'll go through it. So, if you remember the formula, I mean, don't worry if you, if you did, it's like I say, you do not need to know this for your exams. It's just if you want, if you wanted to know it for plastics in general. Um, so it's the formula. The Parkland formula is 4 mL times total body surface area, times body weight. Okay. So here we have four millimeters by 25% at times by 25 times by 70. And that gives you seven liters. But if you remember what I said before, you've got to give half of that within the first eight hours and then the other half within the remaining 16 hours. So there was a few that puts seven liters there. So I think you might have just jumped too quick, too quick there but well done forgetting to seven liters in the first place. Um But yeah, so just, just a question there on, on that one, but don't worry about it. If not final question, final question for, for tonight's session on bones, right? Five seconds. Well done. A lot of people got this one which is very impressive. Um So this one is a superficial dermal burn. Um So don't worry, I've got a table up next. So we'll go through all the different types of bands and then we'll come back to this question and, and show why it was this one. So this is quite a nice table. Um That's just showing the four different types of burns. Um So you can see there named on the side here. So historically, they used to just be called first degree, second degree, third degree burns. But since then, they've split up second degree burns into two different types. So you've got superficial epidermal, superficial dermal, deep dermal and then full thickness. I've highlighted stuff in bold, which I think is worth remembering to try distinguish between them. So superficial epidermal, its appearance is going to be red dry and there's gonna be no blisters, okay. It'll be very painful but generally heals by itself or heels within a couple of weeks. Superficial dermal. On the other hand is pale pink, okay. It has sort of a wet appearances. Hopefully you can sort of make out on this this image and, and it's blistered. Okay. That's, that's a key thing that is blistered as well. Again, though this would be painful, it just takes a bit longer to heal deep dermal. On the other hand, generally. So in some textbooks and on past mint, it has it listed as been a white lesion with erythematous patches. So this image, it looks very red here. But if you can, hopefully you can appreciate sort of these areas where you can see my curses at the base of the fingers, there is sort of white patches, they're of the skin. Um And here at the wrist as well. Um So here's white, generally white, nonblanching erythematous patches. And because it's deep dermal, you've got reduced sensation. But if you press deep enough, then it is painful. Um Both this type and full thickness burns need full grafting though. They don't, they don't heal by themselves. Full thickness again is white. But hopefully, you can make out if they call it waxy white. And hopefully you can make out there is much more of that white image compared to uh deep dermal. And here you've got no sensation at all. So you don't feel any pain because it's full thickness. Um So hopefully those things in old are the ones that I use to remote. Try. Remember anyway, the different types. So hopefully that comes in handy. So if I go back to this one, so you got partial thickness, superficial thermal burn, which is this one here, the second option. Um So it comes in and doesn't mention anything about pain, but it doesn't say whether he does or doesn't have it. But the key thing here is pale pink skin um with blisters, okay, go forward, pale pink with blisters and it's painful. So it fits that description quite nicely. So, yeah, so if we finished on time, this session, which I'm quite proud of, but yeah, just a short session on burns and skin cancers for plastics, like I said at the start there is a lot more that goes into plastics. It's not just those two teams, but there's a lot of overlap. So we'll cover hand trauma when we do orthopedics. Um, this cleft lip cleft palate, which I believe we touched on a pediatric surgery, um, sock home as there's, there's all sorts, um, which I'm sure, you know, if you, if you're coming along to a plastic session, I'm sure, you know, before you leave, please, please, please, can I ask you to fill out the feedback form? Um If there's anything that you think could be improved, please put it down. Um Anything that you think worked well again, please put it down just so we know for our future sessions. Um And yeah, we've got other sessions coming up. We're almost halfway through now. Um So as we get closer to people's exams trying to cover the more high yield stuff. Um, so our next session is on Tuesday, on Jen surge. So we're gonna cover esophageal disease, hernias, bowel obstruction, and maybe, maybe something more as well. Um So yeah, so thank you all for attending any questions, I'll stick around if you want to put them in the chat and I'm happy to go over any other questions, any previous questions if, if anyone wants me to? Um, but yeah, thank you very much for spending your Thursday evening with us. Thanks a lot guys for coming. Be sure to fill in the feedback forms. And join us for the next session or on Tuesday. Right? I don't care. No worries. No worries. I don't think we're getting any questions. So I think, I think we're all going to leave the session there. All right. See you guys later. Thank.