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Mhm We live now and hi everyone. Thank you for joining. Um We've got about 9, 10, no, 89 participants so far. So we'll just make a start. Um Welcome to the night application course. I hope this is your first time coming to our events. But if it is thanks for coming. Um If it is your first time and you'd like to watch the recordings, please do, they're all on the meal. Um and do just fill in the feedback when you watch those as well. Today we'll be covering. Um Yeah, my audio is really bad. I'm apologizing in advance. I'm literally still in the hospital. Um The other guy's audio will be much better and they're the ones actually teaching you. So don't worry, I'm just going to introduce and I'm gonna leave. Um So this this uh session will cover the clinical station structure. Um It will go over your a to e everything that you need to mention when you do your clinical interviews. Um and they will go through a brief example, things like that as well. Um The speakers today are Doctor Jo Josh, you and Doctor Angela Kumar who are both S FP doctors at the Northwich. Um, and they're going to be covering the main stuff. Um, in terms of other, less like admin stuff, that's our email that's on screen at the moment. If you haven't got a mock interview and you would like one, I do have some interviewers spare. So please email that if you want a mock and you haven't got one. Um And those are our social medias to keep up with the next event. We've still got one coming up on A to ES and we've got one in January on S FP offer day for making the most of your S FP questions. Can you go to the next one? Uh as per this slide? Um So that is what's left and what's coming up? Cheers, I'll um I'll hand over to you then just to carry on. Um Everyone, I will just send the feedback link in the chat now just so that it gets emailed to all of you at the end. Please do fill in the feedback. It'll be really helpful for all the speakers and for the calls going forward. All right. Thank you. Ok. Thank you, Cathy. Um, hi, everyone. I'm s I'm one of the ones at Norfolk, Norwich Hospital in East Anglia and you've probably already met Angela before, but I'll let her just say hi, hi guys, I'm Angie. Um Again, that's ap at Norwich in Norfolk. Cool. So today, uh we would like to kind of go through the A to E station, uh kind of overall the structure how to approach it. And a few top tips that I think we would like to share or would like to advise you guys um for this kind of section of the interview. Um So it's kind of useful for the interview, but it's also good for Aussies where you'll have to do A to e like approach or, and then it's also good for actual being a doctor too because when you have to take care of unwell patients on your own or if you're the first person to see them, it's a good general structure to have in your head. Um So yeah, hopefully this session is useful. Um I think if you guys have any questions, just pop it in the chat and I can try and get to it if it's relevant for the time. But if not, you can, you can have some Q and A at the end too. All righty. So for the clinical station structure, um the specifics will vary based on which scenery. Um You'll be doing your SF E interviews for, but in general, it's usually 10, maybe 15 minutes for Norwich. I think it was 10 minutes and I think it can feel quite pressured and time tight. And I think in general the interviews you don't have much time. So everything you say kind of should, you know, be useful and try to make it count. Um But essentially for this er, structure, the, you'll be given a scenario and usually you do get like 10 or maybe five minutes to read it, process it maybe write stuff down uh just kind of get your head and the have a kind of initial think about what you might say. Um and then you go into the station um and then it's kind of on you to kind of talk through what you would do in terms of managing this clinical scenario of an unwell patient. Um, kind of, and then in, from my experience, you kind of talk through what you would do rather than kind of talk to the examiners as like they're the patient or something. That might be something more in an ask that you do. But from my experience, you say kind of things like what you would do first or, um, and then you can ask them about different managements or, oh, sorry, not management, the different investigations or bed bedside tests that you can do. Um, and then usually, um, they might, um, give you a few follow up questions at the end, but this varies on, on the kind of deanery, I guess that's running the interview and mainly it's about kind of further management or who you would escalate to, um, and things like that. So, um, what I'll be doing is just going through the general a three structure and then we'll do like a run through together at the end. Um where hopefully some of you guys can participate as well. So, um the kind of initial steps even before you begin, the A two E um these are kind of the four points that, you know, I have in my head when I'm seeing a patient and, but these are the things which I said in my interview as well. So it's kind of basic stuff but kind of think out loud and kind of try and say what you would do, even if it seems more things like washing your hands and putting on PPE and things like that. Um So these are the first kind of main things you do. And also at the bottom, I've put here something that something you could say as well at the start just to kind of make them understand that you kind of know what you're doing and this is practically what you would do in real life as well. So I think that's the main thing that trying to assess um for this a two week clinical structure station um is that, you know, are you safe and are you systematic in kind of dealing with an unwell patient? Um And they don't, I don't expect you to know all the management options are all like the 2nd and 3rd line kind of treatment. It's more about can you assess this patient? Can you kind of correct any initial um issues or problems that they're having and then knowing when to escalate and call for help is a big part of this um kind of station as well. And I think you can call for help at any stage, you can do it at the start. If you think they're really unwell or you can at the end say, you know, I've done my A to E so now I'm going to escalate, but in this initial steps, um these are the main things you do to just introduce yourself, confirm the identity and then if possible take a history and then you can mention as well when you're taking the history, you also um assessing the airway, but we can get to that in a bit. Um So the first stage of the A two assessment would be the airway. Um And the main thing you're, you're kind of thinking to yourself or the main thing you can ask the examiner is when you're taking the history was the patient speaking in full sentences. So with all stages of the A two assessment, I like to take it in like a look, feel kind of move slash examination approach. So you're, you know, and you can say as well, you know, I'm I'm taking a look, feel, you know, um as assess uh approach. And so you can say like I'm looking at the patient, are there any signs of a way compromise? And you can say things like noisy breathing or accessory muscle use or, um, like, are they especially drowsy, drowsy, for example. Um, and then you can say as well, you'll have a look in the mouth. Um, and you know, if there, if there is any airway compromise, usually the, um, the examiners will make it quite clear. So they'll say, oh, your airways fine and then you can move on and you don't have to worry too much. But if they say things like, you know, noisy breathing or drowsy, the main kind of things to do initially, so you don't need to all, all the time, just call the, you know, anesthetists. Initially. The main simple things is the, that you should mention that will give you points is the head tilt and lift and see if that helps, you know, lift the airway compromise. Um And you can also jaw, jaw thrust as well. And if that's helping maintain the airway, then the next thing you can do is insert one of these airway chunks as you can see here. So, on the bottom left, that's a MP. So nasopharyngeal and if that doesn't work, you can consider a, um, oropharyngeal one which goes um into the mouth. Um And that's more if they're drowsy cos if they're fairly alert, they won't tolerate the, the um op and then the on the bottom, right, that's an eye gel. That's mainly for your cardiac arrest and kind of fully unconscious patients to kind of secure the airway. Um And I guess at this point as well, I put in hypo oxygen, it's something you can consider, but it's more of um kind of the b part of the assessment, um which I'm going on to next. So again, with it would be breathing, the main thing is what you're looking for is work of breathing cyanosis, um and also are coughing or anything like that. Uh So those are the kind of main questions you can ask the examiner to get you a better understanding of, you know, how their breathing is. And then the main observations to do is you would count their aspirate and then ask the nurse or whoever's with you to kind of put on O2 sats and then it's quite basic stuff and I'm sure all of you guys know it already. Um if the, if it's low, then you would put um put on oxygen usually 15 L um non rebreathe. And I think, I think what I've been told from the various als courses and talks and from in general as well is that even if they have COPD, it's OK to give, you know, 15 m non rebreath initially. But you can just say, for example, if you know, in the, in the vignette or in the scenario, they've mentioned CO PD, you can say that you understand that, you know, in the acute acute setting, you can give 15 L. But after that, you can titrate down using Turi cos you don't want it over. Uh Especially if they are C CO2 retaining, you don't wanna give them too much oxygen. Um The next thing you would say is that you do a respiratory examination. So just as I've put here, just talk through it systematically, you'd feel the trachea, has it deviated, um assess chest expansion, percussion and finally, auscultate. Can you um hear breath sounds bilaterally and are there any added, sounds like crackles or wheezes? Um And once doing this, you can kind of say, so you've done the assessment um if they're kind of hypoxic, you've given the oxygen. And also if you've usually Hawaii, next thing in my head is if there were any positive findings or if there were any issues with B just, just say you'd request or you would consider requesting an ABG chest X ray. Um And then peak flow is mainly for, if you think it's acute asthma, it's quite useful because um depending on what the peak flow is, you can categorize if it's, you know, just severe or moderate or life threatening asthma, for example. And so I think that's like a low key investigation that many people don't kind of mention. But I think it's a good one to, to use because it can give you a lot of information. Um That's everything on breathing, I think I wanted to say and I don't think there have been any questions. So far. OK, cool. I'll move on. So after brief and then the other thing to mention is that there's no one way right way to do it. Um Some people suggest that, you know, after a say that you would go to B and then before moving on, you would reassess A and B before moving on, for example. But I think me personally, I usually do A two E and at the end, I just say reassess, but there are more than kind of one right way to do this. This is just how I think I would recommend or how I advise. So next is circulation. So again, we're doing the same kind of system. You're having a look and the main thing you're having a look for is um if the, if the patient is obviously full over or dehydrated, and also the main thing is you can ask is, are they warm and well perfused? It's like a very common but simple thing you can ask is if they're cold and per freezer, shut down, it gives you an idea that the circulation isn't as good as what you might hope. Um The main observations to consider for this section is um or to remember is heart rate and BP. Um with heart rate, I guess if it's high or low, you can just, just think to yourself if it's high or low consider EC G and I think if there's any chest pain as well, consider an ECG. Um, and then other thing with BP, I'm sure, you know, if it's hypotensive so that you would give fluids. Um, so usually what I always say is, and what most people say is, you know, two white Bull Cannula and the ACF and before giving fluids take blood. Um, and then you, if you, if you're kind of ha usually what I do is before saying all of this, um I kind of before taking blood, I quickly ask, is there a temperature as well? And that's because if they do have a temperature, then I say take routine bloods like FP CSE. And you can think of other things that are relevant, for example, B MP and heart failure um or other specific drug, uh other specific blood tests for different scenarios. Um And you can say I'll take blood cultures as well cos they've spiked temperature. Um So that's heart rate, BP and then similar to B that you do A um four C, you do a cardiovascular examination. Um So as you, as I put there, it just consists of kind of feeling for the heart um feeling the apex beat if it's enlarged. The main thing is looking at the JVP, that's really useful to kind of assess the fluid kind of level. Because if it's raised, they might be, they might have heart failure, they might be overloaded with fluid. And the other thing is listen to the heart, is it normal heart sounds? And are there any murmurs that you can hear, um that would, you know, be causing the heart failure or just, you know, give a better picture of what's going on. And I think the final thing is the fluid balance assessment and it's something that is sometimes missed out of um circulation, but it's really useful. So kind of J DP is part of it. You can talk about mucous membranes if they're dry and not skin tag. Um But the main thing you can ask about is, you know, urine output. Is there a fluid balance chart or when was the last time that if they peed, these are all things that, you know, would tick the box in this kind of assessment, you know, kind of sub assessment of circulation. Um So going on to management. So I've already talked about, you know, if they're hypotensive or if you need blood, you know, you'd put in the cannula if they don't already have some in, take blood, take cultures if necessary, give fluids and with fluids, um usually 505 100 mL uh stat um if they don't have any heart failure or if they had heart failure, 250 is the go to um those are the numbers to remember. Um I um as I said before, any kind of chest pain or I think it's just, I think it's all I think if it's relevant, you will know if it is, but I guess if there's any chest pain or if there's tachy or Bradycardia just do an E CG, see. Um, and you know, they'll, if it's relevant, they'll give you the results and then you can interpret it and go from there. Um, but there's no harm in asking for one. And then the final thing is, um, you can consider a catheter um, mainly for your sepsis, heart failure patients. Um But in general, if they're acutely unwell, it would be good to have a catheter. And if they ask why you can just say to monitor fluid output, um it's a good, good thing to say if you're stuck. Um So that's circulation. So moving on to disability. So I think OB and C are the main big chunky parts of the at assessment. If you can kind of slickly navigate your way through that, then overall you should be out of the woods if that makes sense. So with disability, the main thing is um assessing your, you would say to the examiner, you want to, you know, assess the level of consciousness. And I think personally, I just use AF two and I think given, given the time scale and also are like what they expect of you. I think you can learn G CS if you want. But I think just say, you know, are they alert? Are they confused? And or if no, are they, if they're very drowsy, are they, um, alert to voice or pain. I think it gives you lots of, like a fair amount of information. Um, I'd be surprised if they want to know but if they cos it, I don't think there's enough time to, for you, for them to, like, make you work out at G CS and things. Um, so that's my kind of advice on that. But if you know it, that's all good. But I don't think it's too deep if you don't go out of your way to kind of learn it. Um The other thing with, um D is the level of consciousness, look at the pupils, are they, um, equal and reactive to light. And then the other thing is always glucose. Um, and temperature, if you haven't already mentioned a NC, um cool. And then in terms of management, it's essentially if it's low, low BMS, you can correct it by giving Gluco gel, um, or the especially drowsy, uh, you can give IV Dextros and then if there's, you can kind of ask as well, is there any, you know, focal neurological deficit or even if they're confused or, um, kind of drowsy? Uh You can, you know, especially if they've had a fall and they're on blood thinners, it warrants like a CT head. Um I think it's worth mentioning in this kind of session. Uh For example, if they've had, but I don't know if they have a stroke or if they've had a bleed in the brain and they're confused or there's some neurological deficit, a CT head would be, would be quite relevant. So that's disability and then the last one e for exposure. So in general, what I say is I'm just gonna do a head to toe um assessment now, um just looking at the the person or the patient looking for any signs of rashes, bleeding bruising, um or any other kind of a signs. Um And you know, you can say that, you know, you would look, uh look, you know, look under the bed or turn them, turn them around or, you know, whatever you feel comfortable saying. Um And the other main thing in E is the ABDO exam. So to just fill for the abdomen, is it soft and tender and also fill the calves as well? Is that soft and tender? The other stuff you do in e is dependent on what the presentation is. So if it's like a stroke, clicking picture, then you can, you can obviously do your upper and lower limb. You can say that you'd do an upper and lower limb neurologically exam. Um Not sure what else would be relevant. I guess if they've, if it's more musculoskeletal, then you can do like a shoulder or like a hip exam, but I think it's less, less relevant in a in acute setting. Um And then of course, if you notice any um any bleeding, you can kind of ask, you know, how much is it? Can they quantify it? Do you need to activate the major hemorrhage protocol? Um And I think the only other thing to mention is that if you're thinking is obstruction, um or if they, they're vomiting and the abdomen is sust as things definitely like consider doing APR to look for Melina. Um or um yeah, that's the main reason to be fair or if, for example, it's like, I don't know, quarter equina, you might wanna consider apr at this stage to assess for anal tone and all of those had anesthesia, things like that. Um But in general to simplify it, the exposure is, are they bleeding, are there any rashes abdo exam? And then maybe consider pr if it's like a surgical like acute abdomen or if it's relevant for this scenario. Um So yeah, that is that. So the last thing I would kind of say is so after I've done my A two ei would you reassess and I would also escalate to a senior doctor if you haven't already said help. And like, and I think it was always good to kind of have an idea of who you would escalate to what, what we were told is you escalate within your team. So, you know, you, you're F one so you can go to your F two I MT who's on shift with you or go to the ra your consultant um or it can be like, oh, if you know it's a surgical problem, you can call the on call surgical registrar. Um or if you know it's a stroke, then you can, you know, go for the stroke consultant or the stroke rage. So if you kind of know what department you're calling for, help for that can be useful. Um So I think that's everything I have to say about the A two E hopefully it was useful. So I think we're gonna now go through like a scenario together. Um And I think the next session will be more of the same, but yeah, I think that was a very thorough and like structured approach. Um Does anyone have any questions before we move on to the example just to add um because Jills did mention if it's, if you're worried about bowel obstruction or perforation, if someone's vomiting um something to put in as a NG tube just to make sure they don't aspirate. So that will be part of your E. Mm. That's a good, yeah, that's a good point. Thank you for raising. OK, so how are you? Mhm. Um No questions in the chat. Um But feel free to drop any in. If you guys think of anything for the practice run through, we have a scenario and we're gonna try to keep it as inactive as you as we can. So if we can just have a read of it and then we'll go through the at e systematically and just talk through it. And if people can put it in the chat, what they would assess in each of the stages. So the scenario is that you're an F one working in AM U clerking patients, you've been asked to assess Robert, a 67 year old who's become increasingly short of breath. This patient was admitted today for investigations into shortness of breath and has been treated by the GP for a chest infection, um, which has not improved despite antibiotics. So this is the patient you've been asked to assess using the AT E model? Ok. Does anyone wanna it say what they're looking for with air way? Just type it in the chat. Yep. So Robert is talking in full sentences. So, what does that mean? It means the airways open and patent? Thanks you. Yeah, I think if, if the person's speaking, you can assume it's patient unless you can hear any sort of wheezing or gargling or odd noises. Um, so you don't need to ask them to open your mouth if they're awake conscious and speaking, um, fine and in breathing, what would you be looking for or how would you assess breathing? Yep. Any odds you'd like? Yeah, respirate oxygen sats. And that gives you a general idea. Um, anything else you'd like to do for breathing? Examination wise? Yeah, let's go take the chair. So, yeah, make sure to look for tracheal deviation and erin as well. So Robert has respirate of 30 equal chest movements. His oxygen sats are twen 89 on air and 95. Once you put on 50 mL of oxygen through a non ruby mask, there's a dull base with reduced air entry on the right side. Um, at this point, any further investigations you'd like? Yeah. So sure. Um, looking at the breathing after that, you'd be like, yes, he needs an ABG. Anything else? Yeah, you can consider a chest X ray too because it's quite obvious that it's a respiratory issue at this point. So you can ask someone to get that in the works next. Uh, looking at circulation. How would you assess this? So it's always really useful to think of it as obs like things you can measure. Yeah, like heart rate, BP and then also things you can examine. So for circulation, you'd look at heart rate, BP, you'd look at cap refill time and listen to, um, yeah, exactly. And listen to the heart for any murmurs. Yeah, and feel the pulses look for J BP signs of heart failure until the feet. Right? Just a very quick cardio exam. I think what you get good at in real life and like assessing patients cos I use at e almost every day at work when you, when I get to, when I get asked to see a patient and you get good at like going for the, just the very cool stuff. Yeah. Third date is to you out. But, um, fine. So this patient has a pulse of 100 and 20. So he's tachycardic. He's hypertensive, he's got a capri full time of four. He's got a temperature and when you feel you feel that he's hot and his last pass urine three hours ago, but he still has warm peripheries. What are you concerned about here or? What would you do? Yeah. Septic six. So we're really worried about s sepsis specifically for the um tachycardia and hypertension and reduced um cap you full time. So yeah, getting IV access, get some bloods, get a lactate. Um put in a catheter to monitor fluid output, get some blood cultures at this point. You can also consider just giving them paracetamol to try to bring the fever down. And yeah, you'd also go by trust guidelines and give them antibiotics as part of your sepsis six and you already put them on oxygen. So I think that covers everything. So now moving on um to disability, what sort of things are you looking for? G CS? Yeah, pupils and temperature as well. Um Yup, chills next slide. Um Yep. So he's alert, pupils are equal and reactive and blood glucose is 5.6. So w is there anything to do here? And just a quick tip? I always just go with ADP so alert, verbal responsive to pain, unresponsive rather than G CS, especially for interview situations. Cos it's a lot easier to decide where on au you are rather than G CS cos the interviewer could turn around and be like what G CS is he? And then you're trying to work it out in your head. Ok. So there's nothing to do on disability so we can move on to exposure and what would you like to do here? So in exposure slash everything else. Yeah, you expose the patient ideally from head to toe. Um you're looking for any rashes, any do an Abdo exam, consider pr but not relevant in this patient. See if they're bleeding from anywhere, um check their calves to see if it's soft and nontender. Cos you're worried about a DVT that could become a pe as well and shortness of breath and just have a look all around fine. So, abdo softener, tender, calve softener, tender, no rashes, no bleeding. So that's fine at this point. What would you like to do? So, in an interview scenario, you'd I think you'd expect to get through your at e within about 4 to 5 minutes and then the rest, the other half of the interview would just be talking about escalation management, er or reassessing. Perfect. Yeah. So at this point, you'd double check, you've done everything in sepsis six and then you'd hopefully the ABG would have come back and then you can also reassess. So hopefully, as you go on along the oxygen has improved, the circulation's getting better with your fluid bolus, with your antibiotics, the temperatures coming down. So it won't be immediate. But yeah, and escalating to a Zenia, it's also really important. So in this case, sepsis is quite important in terms of managing it quite quickly. Who um if you only asked, who would you call? Um So if you're an AM U, you probably have a registrar you're working with or a, a consultant. So just alert it to your own team, just be like we have a patient that's possible sepsis. We just keep an eye on it and then they can come double check um and suggest anything that hasn't, that has been missed or needs to be done. So I think for the sake of as af one as a final year medical student or in the interview case, you just need to safety net. Make sure you're being safe. So, escalating to your own team is really important. I think I personally wouldn't escalate this to respiratory because it's not particularly complicated yet. I don't know if she agrees with that. Yeah, I know like there's chest sepsis. But yeah, unless they have like COPD or empyema or something like that. Yeah, you wouldn't really call because sepsis is something about the general headache. So like your, I guess. Yeah. Yeah, like, yeah, like a, a non specialty team can handle if that makes sense. Yeah. But I think if you're on au um like your medical reg would be able to handle this. So I think it depends on the brief but if the scenario is you're on nights you're on, you're by yourself in the definitely call the med reg. Yeah. Agreed. Any more questions. Mhm So yeah, anything to anything to add, chills. Uh No, nothing to add. Yeah, this was just, yeah, it's just a slide on sepsis six which um said um yeah, it's important in sepsis to just consider this. But yeah, that's all. Um And uh just go back to the slide with the lactate. It should be done in the ABG that you're doing anyway. Yeah. OK. Um So that's the end of the example. Does anyone have any questions? Can we go through the scenario? Yeah. OK. Um So as you would listen to your oh, how to just speak? OK, fine. Um um GS do you have a preference? Um I can be the, I'll go through the at. OK. So I can, I can be the examiner. Is that what they mean? How would you answer if one was the interviewer? Yeah. Yeah, we can do, I guess. Yeah. So if you just go to the last slide with all the at E stuff in it. Yeah. Um OK. So the brief was, it's a 67 year old that has shortness of breath and has been treated for a chest infection. So I'd start to assess this pa I first introduce myself and then start to assess a this patient in an at E structure. I'd um check if this airways patient, if he's talking. Is he talking? He's talking four sentences? Yeah. Ok. So that I can assume and move on to breathing. At this point. I'd like to do um measure his oxygen sats his breast rate as well as auscultate his chest and puss and do a um chest examination. Ok. So his sats on error. Oh yeah. on error 89%. Uh his res rate is 30. And on your respiratory examination, there has equal chest movement. Um but there's uh on, on auscultation, there's a dull right base with reduced errant. Ok. At this point, uh I'd be worried um about his oxygen set. So I'd like to put him on oxygen 15 L via non reboot the mask. I'd also like to get an ABG at this point to check his oxygenation and see if he's got COPD or any other concerns like that. Um as well as a chest X ray to see if he's got pneumonia. Yeah. Um and can you confirm if the oxygen's improved? Yeah, it's gone up with the 50 m and no rebreath it's gone up to 95. That's all good. Ok, so I'm happy to move on to see circulation. So I'd like to get a heart rate, a BP check. Um central cap refill time as well as um listen to your chest. Um heart sounds um exam exam too. Ok. So pulse is 120 BP is 95/65 refill time is four seconds. Um And yeah, on the cardiovascular exam, heart sounds are normal. No added sounds. I'd also like to quickly assess fluid um status. So just check the oral mucosa, ask when fluid um urine was last passed. Ok. So um mucous membranes are dry and um urine was last passed three hours ago. Ok. So as he's tachycardic and hypertensive, I'd be worried about um uh shock. So I wanna give a fluid bolus 500 mils of saline stat. And I'd also like to um measure his temperature at this point because I'm worried about sepsis. Yeah. So he's uh paraxial 39 °C. Ok. At this point, I'd like to start sepsis six. So he's already on oxygen. I'd like to um take, get IV access as well as take um a lactate um-hum and normal bloods and send that off. Um I would like to take blood cultures and then give him, I've already given him a fluid bonus, but then also a fast bag of fluid afterwards and antibiotics according to trust guidelines, uh I'd like to reassess his circulation at this point to see his BP and pulse is improving. Yeah. So after the bolus, the BP has improved a little bit. Um Yeah, that's it. Ok? Heart rate is still high, but it's coming down. Ok? Um I'd like to move on to disability, um, assess his au his pupils and check his blood glucose. Ok. So he is alert to voice. Um, pupils are, uh, pupils are equal and reactive to light and his blood glucose is 5.6. Can I also check his temperature again? Oh, yeah. Uh, it's still 39 it's like 38.5. Now, I like to give him some IV paracetamol. Sure. Ok. Um, and moving on to e I'd like to expose him head to toe, check for any rashes, any bleeding, do abdominal examination as well as check his calf for any swelling or tenderness. Fine. So no rashes, no bleeding, abdo is soft and tender and calves are also soft and tender. Ok. So at this point, I'm worried about chest sepsis, um possibly pneumonia. So as I'm waiting for investigations to get back to me, I would just like to speak to my registrar. So the med reg and explain what I've done and see if there's any further steps to do. Ok, perfect. Yeah, that's it. Yeah, I think in real life they'll be like, I'm sure they'll think of some questions to ask like I can't think of anything in my head right now. Um I'm a bit out of practice doing it verbally as well as I've just come off nights. So, uh I hope that helped um for some clinical examples from de reasonable, multiple variations, deteriorating any points, themes, prioritization, fine. Uh I think using the at E model for prioritization as well is quite important because if there's an airway problem or breathing problem, it's much more important to attend to initially than um say someone with a rash. So usually what they'll do is give you a non urgent job such as, oh can you prescribe these fluids and then something like a possible septic patient, which it should be quite high in your priority list And then maybe some increase in pain for an abdomen patient, a surgical patient. So the surgical patients important because we don't know what they've come in for could be a perforation or an infection. It could be something getting quite bad. But sepsis patient would be first cos with sepsis, they can deteriorate quite quickly. And yeah, that would be the priority. I think so for no, you don't have to prioritize. And I think for my other one, I did, but I think I just used at e to see if it was an airway disability, airway breathing circulation disability or um everything else problem. And you can kind of use that structure to justify your prioritization, but it shouldn't be um too complicated. They're not gonna give you two dying patients and be like, choose any other questions. Ok? You're welcome. We really hope that helped. Um Again, if you guys need more interviews, please email us and we can try to fit you in in a spare slot and good luck. With the process and good luck with interviews. Mhm. All righty. Thanks everyone. Hope you have a nice weekend. Please do fill in the feedback that we emailed to you guys or it's in the chat, right? Yes. High up in the chat or, but if you've attended, you'll get a little email too. We really do appreciate your feedback on how we're doing things and how we can improve it. Ok, perfect. All good. All right. Bye. Thank you. Bye.