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Hi, everyone. Can you give me a call? Hi. Anyone? Can you hear us? Hi. Yeah, thank you. Yeah, very young. Right. Ok. So I think we're gonna stop because sepsis is quite a big topic. Uh, but today's talk is on sepsis and I think we're mainly going to focus on like the, the take home from today's session is to know how to do a full septic screen and how to clock patients. Sorry, noisy in the background. So stop my mic and let her talk. It's, it's a little delayed. So, I don't know you. So, um, today's talk is about sepsis. Uh, my name is Rahma. I'm a GP trainee. Uh, and I am an I MG. Uh, so this topic, sepsis is a very important one and a very big one. Um, I try to, uh, make it in, uh, in a form of a few case scenarios. So we can, um, think of a few, uh, management plans that we can do for different scenarios that can present with sepsis. Um, I tried to cover the basics, um, and I try to make it as simple as possible. So we'll see how it goes So we'll start off with a case and I want you guys to try to put in your own plans uh and please don't be shy to contribute. So it will be beneficial for you to see uh what you missed. What uh what did you learn? And it also would benefit us so and see, have you benefited from the teaching and what we can improve for next time? Uh And then I'll go over uh quickly what is sepsis, the definition, the new score? And we'll go over three cases and then we'll talk about neutropenic sepsis and then a recap. So let's start off with this case. Uh Can you hear someone in the chart to see is saying that my voice is feeble. Can you hear me? I can actually hear you perfectly fine. So I'm not sure. Um OK, so I'm gonna say it's better now. OK. OK. So it's good. So I just want you to try and um see what you think the plan should be for this case. So it's a 37 year old man. He has a history of a double J stent. It's a ureteric stent uh that we can sometimes put for patients like who have um a urine uh urinary stone or something. Um And of course, that can be a source of infection. So any foreign body can be a source of infection. Uh He came with low pain fever, decreased urine output. His observations were he had a respiratory rate of 22 saturation of 97 BP. 100/60. That's a little low heart rate is 120. Um conscious level. He's alert temperature is a little high 39. He's using a six and you can see the bloods, he has um uh a high white cell count, high C RP, high lactate and some acidosis, some metabolic acidosis. So, right in the chart, what do you think the plan should be for this case? What would you do if you were clerking this patient? I'll give you a few minutes. Ok. Urine and C NS. Yeah. Fluid, broad spectrum antibiotics. OK. That's good. Anyone else I'm gonna hand he has a temperature of 39. Yep. So what are we gonna do with that? If you spiking temperatures? There's a very specific investigation that we need to send off and there's something we need to give him to manage the fever. Yeah. Bye. I agree with uh the plans that everyone said, but we can um there are more things that we can do. Yeah. Yes. Antibiotics, blood cultures. Ok. So that's good. Um We will come back to the same case at the end and we'll see um we will see if the, if you have different plans at the end. So let's start off with an introduction about sepsis. Sorry. Uh So what is sepsis like sepsis? Is this vague term that everyone uses? So, sepsis is a lifethreatening and that's very important. It's life-threatening organ dysfunction. It can uh cause damage to any organs. Uh The first organ that is damaged is usually the kidneys, uh but it can also damage any organ in the body. It's caused by a dysregulated host response to infection. So, infection is a big part here. Uh and the septic shock, septic shock is um is basically severe sepsis. It's a subset of sepsis, which can be um which can have profound circulatory and similar metabolic abnormalities. Uh It's clinically identified by the need of vasopressors to maintain an arterial pressure of si 65. So 65 is usually our uh target BP. If the BP is below that, even with fluids, you should give vasopressor um and sometimes steroids. Uh And if the serum lactis is greater than two in the abscess of hypervolemia because hypervolemia can cause those two things. So, why is sepsis important? Why did we choose this topic? Sepsis is one of the uh preventable causes of death. Uh And it requires prompt action, failure to promptly and adequately diagnose and treat infection can cause to avoidable sepsis. And fai failure to diagnose and adequately, adequately treat sepsis can cause uh avoid, it's is an avoidable cause of death. So, uh there has been more than 20,000 deaths uh per per year due to sepsis. Uh Mainly people who are affected by sepsis are elderly. Um people with uh frailty comorbidities, uh immunocompromised patients, uh patients like after trauma or surgery because that can cause infection. But anyone can uh be affected by sepsis. And it's very, very important to recognize sepsis early. Uh and to treat it early, do not ever delay sepsis treatment. So how can we diagnose sepsis? Like how, how do I feel that someone has sepsis? Because all that is kind of vague like how do I know that someone has a dysregulated body response to infection, for example. Uh So we have some uh like scores for sepsis, some clinical scores. Uh the E US score the early warning system or the news, the national early warning warning system. That's the most popular one. There are other scores that are not uh as common like the sofa, the quick sofa, the sir. Uh but we will talk about the news, the news two score. So that's the the new score, the new score. It depends on the observations. Uh the respiratory rate. If it's from 12 to 20 that's a zero. If it's less or more, it will depend on the score, the oxygen. So the oxygen you can notice here that we have a scale one and scale two. So normally most patients are scale one, their target should be above 96. Some patients will be scale two. Those patients uh usually have C OD or any sort of type two respiratory failure. So their targets will be lower to prevent um acidosis to prevent respiratory acidosis and co2 retention. It's a very big topic but just know that some people have a target of 88 to 92. Uh And also are they on oxygen? So, uh if they're on oxygen, it will automatically add two to their score. Uh the systolic BP uh and then the pulse rate and then consciousness if they're alert or if they have any new like confusion or any new deterioration in their conscious level, it will automatically add a three if they are and then the temperature. Uh And I just want to mention that the new score, you cannot diagnose sepsis alone from the new score. It complements your clinical judgment, your examination. Um So for example, if a patient is tachycardic because they have af for example, they will score, but that does not necessarily mean that they have to sepsis. So al al always um use your clinical judgment, your examinations, your findings, your lab findings like a high cr pa high lactate, a high uh white cell count, all of those indicate sepsis. Or if infection is probable that because sepsis, there has to be a source of infection for a patient to be septic. Um Let's jump in to our first case. So this case is a 63 year old man. He came with shortness of breath productive cough. He has a respiratory rate of 22 saturation of 94 on room air systolic BP, 140 heart rate. 64. He's alert, he is not feverish. Um, the slide has not moved. Can you see the presentation? Ok. Can you see the case? Is it case one the 63 year old? Yeah. Can anyone else? It's on the news that the previous slide? So is it the case now? So can you see it moving around? Is it still I try to the slides a little still the same? And can you see the case or the news the table? I can see the case fine. OK. Should I move on? Can everyone see the case know? Oh, yeah. Do you wanna reupload the presentation? I'm trying to. OK. OK. Can everyone see it now? OK. That's good. Yes, you can see it's good. Yeah. So this case. Yup. Finally case one now here. OK. Uh Thi uh 63 year old man uh with shortness of breath and productive cough. Uh He has uh spread rate of 22 saturation of 94 or no air heart rate is 64. Alert temperature is not feverish. Uh When he went and examined him, he has, he had shortness of breath, he's fully conscious. Uh he had productive cough with yellow sputum for five days. Uh on the chest, he found some coarse gravitation in the right lower lobe. So that might be uh some secretions and the abdomen is soft, nontender. So for a case like this, uh we can calculate the new score together. It seems like a chest infection like a basic case of chest infection. Um So those surface should be come come up one by one. But uh let's go for that now. So there birth rate is 22. So he will get uh two points for that saturation is um 94. So one point for that and he's on scale one. So we'll only use the um the first oxygen saturation scale on room air and BP, heart rate, conscious temperature. He's not scoring for any of these. So he had a new score of three for respiratory and oxygen saturation. So this table here uh it divides the new score. Uh So for zero, what will you do? 1 to 46 to 5 and above seven, usually new score from 0 to 4. Uh They will be escalated to an F one to an sho and then above seven should be a specialist like ST four and above the. So for this patient, 1 to 4, uh let's go through this together. So history and examination, uh you should always um do a full history, full examination. Uh see what you think if there's uh a clinical concern or if there is a surgically remedy, remedy of sepsis. Uh or if there's an evidence of organ dysfun dysfunction, for example, an AK I you should escalate to them, you should consider them the next um step. So if this patient had any of these things, we will consider them the next step, which for now he doesn't. Uh and also uh consider the comorbidities. Um the seeding of care uh in the life care, all the things should be um considered for all patients when you're clocking them, at least monitoring and escalation. Uh So it should be, he, this patient should be um reviewed by a nurse within one hour of, should be between four and six hourly um initial treatment within six hours and then source of infection. In this case, it's probable or definite, he probably has a chest infection. So within six hours, you should have your microbiology tests, antimicrobials uh started or reviewed. If they're already started, you should identify your source. You should uh contact micro if you're uncertain all of those within six hours. Um So with antimicrobial use, uh I'm not gonna go through this, don't worry. But uh you should always check the policy. You should always check your policy for which antimicrobial. So uh someone mentioned broad spectrum antibiotics uh for a patient which is not totally uh for the case that we started with, which is not totally incorrect. Uh But you should uh know which antibiotic is suitable for each infection. So for a pneumonia, for example, uh if it's um community acquired, uh you should calculate the curb uh 65 score and see which antibiotic you should give. Can I just pause you there? Sure. Uh So I asked the question, how do we assess the feeling of care in septic patients? So if you care for the previous talk, we talked about the three feelings of care and that a lot of it would be dependent on the patient's past medical history and surgical history. Um And also what their physical and cognitive baseline is. So if the patient is sep who septic is a 75 or 80 year old with bad baseline, their feeling of care might well be ward level. But if it's a younger patient who doesn't have any obvious comorbidity uh is mobile independent doesn't have any cognitive deficits, then the feeling of care would be for full escalation, which means they would go to ICU if they deteriorated. Um Does that answer your question? So it's case specific. It depends on the patient, the patient's baseline, physical and cognitive function. Yeah. See the care is one thing that you have to get comfortable with and you will be more comfortable with it. Once you start working, it's very care specific. It depends on you think this patient is suitable for CRP. If you think they're suitable for ICU. Yeah, I think once you start seeing a few patients, you would start to pick up on the type of patients that aren't going to survive. CPR Yes. And you just wouldn't want to put a tube down their throat. You, you'll start seeing who's frail. A lot of these patients already have frailty as a comorbidity. They might have atrial fibrillation. They might have had three MS in the past. They will have lots of things, asthma, multiple hospital admissions. And, yeah, and you'll see your basic function or the independent, usually how many times have they been admitted or they like a maybe even a it, like you will pick up on those things. So, if you missed the last class, I believe it will be recorded, right? And so yeah, so it's recording and I do think you should definitely go over it because you'll understand how to clock, which is basically what the rest of the teaching sessions are. It's how do you clock this patient and how do you come up with the management plan is the most important one because all the rest of decisions uh build up on the first. So if anyone missed that first teaching, I would recommend you go back to test. Additionally, we are going to cover frailty in geriatrics in the teaching. Uh So I believe that one will really, really help because when we do cover elderly care, um a lot of patients you see in the hospital are elderly. So once you learn how to manage elderly patients and you realize that actually their plans aren't the same as everyone else's plans. And 90% of the plans you do are for um it makes things a lot easier for you. So we will wait in in the future. Ok. So let's continue with uh the plan for this case if you don't have any other questions. Uh So for this case, it's uh likely uh a simple chest infection. It could be a pneumonia or a lower respiratory tract infection depending on the chest X ray. So, what we'll do first is blood, full blood um hemoglobin or the anemic um white cell count, crp lactate ph and the full um bloods, not just those ones, but those are the most important in a septic patient or a suspected septic patient. A chest X ray. If there's uh a consolidation, that will be a pneumonia. If there, there is not a consolidation, it will be a large re tract infection because uh clinically they have a chest infection and not all chest infections appear on a chest X ray. We will do a virology swabs. Um And sometimes we will do further investigations like sputum culture HIV screen and urine liguilla and pneumococcal antigens. Um All of those are, are uh basically the um identification of the source. So if you remember from the previous slide, source identification should be done within uh six hours, uh the ops should be done four hourly as they are scoring a three antimicrobials. So again, according to the policy to the local policy, wherever you're working, um Y uh and a uh chest infection, you will probably have to calculate the curve uh 65 score which in this patient, it will either be one for if it was high or zero because uh, he didn't score for BP or stress rate or confusion and he was below 65. Um It would probably be something like amoxicillin. Um So IV fluids, uh why did I write carefully with it? Because uh a lot of patients who are elderly, um, have a lot of comorbidities. They might overload very quickly. Uh So you should be careful about that. So um when you examine them clinically, you should examine the, the legs, examine the chest for any signs of overload. Uh see if there's any edema. Uh see the chest X ray for any signs of overload. Uh But generally in septic patients or patients who were worried that they might go on sepsis, uh We give them IV fluids, that's one of the very, very important initial managements of sepsis. Uh And then we can give paracetamol for the pain and the fever. We can give a slight sustain for the sputum because if you remember the patient had a productive cough and uh gravitation, uh course, gravitation will probably be uh due to these secretions. Uh the oxygen target for this patient will be uh above or equal to 96 because he's K one, he doesn't have a type two breast failure. Uh And the ce of care, we did talk a little about the feeling of care. Uh And we will talk to it again, uh, on the frailty, uh, elderly, uh, teaching. So make sure to not miss that one. Uh, vte prophylaxis should be considered in all patients. So, vte prophylaxis is an important thing. You should not miss, especially with elderly patients who are what will likely be, uh, less mobile and comorbidities. You should always consider the other comorbidities a patient has and, uh, prescribe any regular medications that they, they are usually on. So that's our case. One. Can I just add a few things? Sorry. Sure. Um Right. For bloods, the only thing I wanted to add is if you're on call and you're following the bloods are usually done already by A&E team. Yeah. Um and you're able to look at them before you see the patient. So after you've seen the patient and you've clocked and you come up with a plan, if there's anything additional that you'd like on the bloods, you just have to send an add-on form because they've already had bloods taken and actually keeps that sample for 48 hours. So you just send an add-on form to the lab and you just write on that add-on form or type wherever it is, what additional test do you want? Uh and you send that off and you just chase those. Then the second thing I wanted to ask or add was why, sorry, not, why if um chest X ray is clear and they've come in with a shortness of breath or whatever presentation are you going to treat them if their chest X ray is normal? So, does anyone have an answer? Let them try and answer the question and we'll figure it out right now. So if someone's come in chesty and the chest X ray is clear, you're still treating them for their symptoms, they've come in with shortness of breath clinically. Um, a yellowy green sputum, these are signs of pneumonia. So, regardless of whether a chest X ray is positive or not, you still need only treat them for a chest infection. And the additional thing is with regards to antibiotics. Um even though we have a policy, everything has to be judged clinically. So if you give someone that's coming with am mild pneumonia, so their co 65 is mild, it's like a one or a two. And the policy says to start them on oral antibiotics, but actually, you've seen this patient and you feel like this patient could become septic very quickly or they are quite unwell clinically. Um You don't need to prescribe antibiotics according to the policy and their C score, you can go off clinical judgment and start them on IV antibiotic. So you're still following the policy, but you're treating it as a severe cap. Um So you just have to use your clinical judgment as well as looking at the policy. Obviously, don't prescribe antibiotic stuff in your hospital, still follow whatever it is like in terms of escalation, mild, moderate or severe. But if someone's coming in with milder pneumonia and you feel like actually this patient is desaturating, I think we should use IV antibiotics for at least 24 hours. You just put on your plan treat as severe even though there's they've got like a mild curb score. Um Sure, I agree. The C score, you can treat them as a higher score. So this patient had ac one but you if clinically you feel that they're unwell, you can treat them as. Yeah, so don't just go by the book or yeah, you just need to be able to justify your management. So wherever it is just make sure you document it. So you'd right. The patient has a cap score one or two, but treat as severe. And your reasoning is this patient is desaturating or because they could become unwell and septic quite fast or whatever the reason is as long as you're able to justify it, no one will ever say anything to you and we're always able to uh step down the ivs to orals. Um So that's another thing I would be really careful of is with elderly patients that come in with infections, they can become quite confused, delirious and septic very fast. So if you think actually I'm worried about this patient, uh they don't look so well and I think they could deteriorate quite fast. Um If they're like a little bit aggressive. So they have hyperactive delirium. You're like, actually this patient's probably going to become septic, just start them on ivs. And you can always write in the plan to review antibiotics and step down to oral after 24 hours. Uh because that will save someone's life and it's better than just giving them orals because the policy said for ac of one, give them orals and send them home. You don't want to send someone that's potentially going to become septic home. And again, um elderly patients, they become unwell quite fast. Um I think the other thing I wanted to add was I I'm not sure if you guys know what we're talking about if we mentioned scale one and scale two. Oh, so yeah. So it was that clear when um I talked about the saturation and the scales or do you want me to expand further on that? I just want, I want one of these guys to let me know that they actually know what we're we're talking about. Ok. So do you wanna explain that, Rama? Oh, sure. So scale one or two, let me go back to. Yes. So usually used for COPD patients two is usually for cation. Exactly with type two failure. So what do you mean by type two s failure? So type one is hypoxia only. So if a patient has hypoxia, that's type one. Type two means that their CO2 is high on the blood gas So if a ba uh for patients like this, it's very, very important to get a blood test for chest infection patients at least once uh when you're clocking them. Um and see the CO2 BC two if it's high. So if it's higher than six, so that means they're retaining CO2 high, that's type two respiratory failure. Usually those patients with COPD patients and they will have a chronic type two failure. So in those patients who have a lower target oxygen, they will probably be oxy and chronically type two. That's what we mean by chronically type failure. Like they have their baseline is an oxygen and high. It's a very quick topic and um we have a teaching on COPD. So we will talk more about it then. Yeah, just to summarize scale two is usually for COPD or type 22 failure patients. Whereas scale one, if everyone else is one. Exactly. So scale two is the lower uh it's 92 and below 88 to 92. Um and that's because so they have lowers or two goals, not higher. Yeah. Yeah. Above 90 days everyone else that scale one. So you don't want to, you don't want to give them a lot. If their saturation is 88 to 92 that's fine. You do not give them oxygen um clearer now. Yeah. So the scales are important because if you, if someone's on oxygen, the nursing team need to know whether the patients on scale one or two, if someone's a COPD patient and you put them down as scale one or the nursing team assume that they scale one, they will start them on oxygen because they think they're desaturating. Whereas actually they're meeting their normal uh target saturation goals and oxygen is pretty much like poison for COPD patients if you give it in excess. Um So just make sure you have the correct scales. And I think the last thing that Rahma mentioned on that slide was VT E profile axis. Um Yeah, I just wanted to add for that one. It's actually part of the clocking sheet. So on the clocking sheet, it will always have a box that says VTE profile access and you have to do that for every single patient. And in fact, you are not allowed to for any patient until you've done the VT E form. Uh So you just have to fill in the VT E form and you have to give everyone that's nonmobile uh frail elderly patients. Uh basically patients that are more likely to develop a clot during their admission, you have to give them enoxaparin. Um That's in our hospital, it might be a different, it might be different in other hospitals. Uh And it's according to the EGFR and sometimes the body weight um and you will be on do it. So be careful about that or uh so if they've come in on do you have to put on the form that they are already on do and therefore you're not prescribing, um, enoxaparin. So, just make sure you have a look at their meds and make sure they're not already on blood thinners. Um, and if you're not prescribing it then it's usually, well, to be honest, most of the patients that's come in, we always give them VT prophylaxis unless it's someone that's young, fit, able to mobilize, which is rarely the case in hospitals. Yeah, most likely you will have, you will be prescribing it every single time. So that's just a standard practice for everyone. So when you are seeing patients and you're clogging patients, you do have to do VTA pro and actually also the in the with care is also part of the. So just remember enoxaparin um it's usually 40 mg, I think. Yeah, per per individual. Uh that's if their EGFR is normal, but if their EGFR is less than 30 you give them 20 instead. Yeah. And if their weight is high, higher than 100 you will give more, you will give 40 twice a day if you at least 40 once a day. Yeah, perfect. OK, let's keep moving. So let's go to our second case. So this case is a 55 year old lady. She has been the IBA. Does anyone know what that means? So I purposely put that and that's one of the annoying abbreviations of the NHS it means brought in by ambulance. It's a very simple one. She collapsed uh with a sudden onset of severe abdominal pain. Uh she was found to have marked lower abdominal tenderness to even light touch and MS. So that sounds surgical, doesn't it? Her vital signs were respiratory rate of 21 saturations. Uh of 98 on room air systolic BP was 135. Heart rate is a little bit fast. 103 she's alert and she has uh a fever, her temperature is 38.4. Uh If we calculate the new score, it will be a five. So usually nurses calculate new scores like if they're an any or or it will be automatically calculated in the system if they're admitted. So if we go back to our um uh table here and you score 5 to 6, uh the s should be done hourly. Uh It should be reviewed by uh less than an hour by a clinician. Uh Previously, it was a nurse. Now it's, it has to be reviewed and within less than an hour by clinician. And I know it might not be realistic like with our waiting times. Um but we uh nurses usually escalate the unwell patients. Um The initial treatment should be done within three hours and if there is a probable or definite uh infection, microbiology tests, antimicrobials and source I ification should be done within three hours and within six hours. Uh the source should be, um, the source control should be initiated. For example, if we need a surgery, if we, if we need decontamination of any sort and uh antimicrobials usually are reviewed every 48 hours. So what the plan for this patient will be? Again, bloods usually, uh will already be done. Uh By the time you see the patient you can add on uh if you need something. Uh for example, amylase, if you uh think like of an acute abdomen, uh or if something that wasn't done, you can uh add it on. Uh we, you should get uh cultures microbial test that should be done in this patient. We should get blood cultures. If there's any obvious source of infection, like if there's a wound or if there is anything, you should also get a culture of that uh observation should be done within uh uh should be done every hour for that new score. Antimicrobial should be started within three hours um or even less uh IV fluids, IV fluids, you should uh start IV resuscitation immediately. Uh It's usually uh the guidelines for sepsis is 30 mill per kg. So uh um I if the patient is 70 kg, for example, it will be 2 L and that should be set, that should be immediate. Um uh And that's the bo you'll give a main maintenance after that. Uh IV fluids and micro uh mic antimicrobials are the first two things that you should start immediately in any uh sep sepsis patient and then uh source identification. Uh It depends on the each case. In this case, it's, it sounds like an acute abdomen. So we should get act scan. Sometimes we get um an ultrasound. It depends on the policies and where you work, but usually act scan uh with or without contrast. And if there's uh like an abscess, for example, because of this patient, she's feverish, she has acute abdomen, there's a mass, it might be an abscess, it might be perforation, for example. So if it's a surgically remediable source, as we said before in the table, um the time scale should be upgraded to the next. So you should treat her as uh a new seven. So the antimicrobial should be given within one hour. Um And you should consult surgery immediately for control of the source because patients like this can deteriorate very, very rapidly. Uh You should consult surgery about uh the plan. Um uh if they need further investigations, uh if they're gonna intervene surgically. Uh and also about the feeding plan because if they're going into surgery, they should be no by mouth, uh they might need um a drip and sock, for example, like an NG tube. Uh all of that is will be decided by someone who's a specialist and it will depend on the diagnosis. So don't worry about that, but uh always, always consult a specialist, control of the source should be done within six hours. But if we're treating them as a higher new score, it should be done within three hours. A review of antibiotics within two days if they're well, but if they are not, it should be uh escalated to someone. Um, hi uh of a higher level of register, for example, uh we should also talk about pain control because she will be in a very severe pain. Your hospital will have a policy on pain control. Um Again, see of care, VT prophylaxis and comorbidities should be considered in all patients. Ok. So does anyone have any questions regarding this case? So this case, it seemed to have um a new score of a five. the level of scalation is an ho but because it's a surgical cause, it should be, it should be treated like as a seven or more and should be dealt with uh in a timely manner. OK? If nobody has any questions, we will move on to the next case. So this is our third and final case. It's a 70 year old uh man who was admitted with pneumonia. He has a history of COPD and a type two failure. So we talked a little about type two failure and what that means. He also has hypertension, heart failure and he is a smoker. His respiratory is 26 oxygen saturation is 88 on oxygen. His BP is 1 20/70. His heart rate is 138 which is a little rapid, he's alert and he is spiking a temperature of 38.6. If we calculated the new score based on those observations, it will be a nine. So again, a news of above seven should be escalated to a specialist or a registrar uh should be done with every 30 minutes. They should be like on a continuous monitoring. Uh They should be reviewed uh immediately within an hour by a senior doctor. Uh And treatment should be started with uh in less than one hour. Um antimicrobials should be started within less than thir uh uh than one hour. Uh That's basically how you treat sepsis. So you start antimicrobials in less than one hour. Um source identification and source control. Uh and then review the antimicrobials within every two days. So that's the chest x-ray for this patient and that those are some of the bloods. So in this chest x-ray, can anyone tell what the chest X ray shows? Does anyone have any opinions? You know? Ok. Where do you think the consolidation right left were? Ok. So there might be a consultation on the left but there is something uh much, much more um dangerous there. So there's an overload, an obvious overload. Yeah, blocking called spring angleus. Yes. OK. Costing angle isn't, isn't so clear. Yeah. So the costing angle being blunted, that means there's um an effusion. Uh it's, it's blunted in the left area and you can see the whole lung is kind of hazy and like the hilar hilum area is hazy. The whole lung is hazy. The bronchovascular markings like you can see that like that's the, I think it was called the bad sign or something like um you can see in the central area there. So this chest x-ray shows an overload, a fluid overload and perhaps maybe a pulmonary edema even uh if you remember, this patient has heart failure uh that can predispose patients to having um pulmonary edema and also that will contribute to the desaturation. So, this patient was uh hypoxic and on oxygen, um it can be due to the pulmonary edema in addition to the CO PD exacerbation. Um So, uh and in the bloods, you can see that their cu two is a little high at seven uh under acidotic. It's a respiratory acidosis and the lactate is also high. So this patient is a little more complicated. Uh He has CO PD. Um he is going into sepsis and he is also overloaded from the heart failure and apparently the renal failure because the creatinine was also high 150. So um if if a blood gas was not done, it should be done. In this case, it was done. But like it's very important to get a blood gas for all CO PD patients and the chest X ray. Um uh this patient also had tachycardia. So it's very important to get an E CG and they also have heart failure. So it's very important to get an E CG with this patient. And we should do our screening, our virologist, swabs our sputum cultures, our blood cultures, um the observations should be done every 30 minutes because that's a very, very critical patient. This patient should be escalated as we said before, because of the high new score, it should be reviewed by someone senior. So if you're clocking this patient or if you're seeing this patient, it's very important to talk to, to talk about this patient who the senior antimicrobials should be, should be started immediately within one hour of this patient. It doesn't matter where they are. If they're in the waiting area, you should, you have to start the antimicrobials right there and there uh steroids uh could be given because it's AC O PD patient. Uh and also um steroids can also be given in some cases of sepsis. But in this case, he's AC O PD. So we, we can give something like prednisoLONE. Uh So usually we say IV fluids on the best cases, we said fluids. But in this case, do you think we should give fluids or diuretics? What do you think right down in the chest? So it's a, it's a tricky one because on one hand, they're septic um and they have uh a high renal functions. So an AK I and on the other hand, they're overloaded So that's a, a tricky case. Anyone diuretics? That's ii like that one. Definitely, definitely uh ask for advice for this or, but probably um it will be handled by diuretics very, very carefully. You would not give like uh a large amount of diuretic, but because they're opioid, uh you will ha you would have to follow but you will have to be very, to monitor them clinically. Uh And with labs um and to do a fluid shot, a step of the gland, a fluid shot. Um because with an achy and with overload or with sepsis, all of those are indication for a fluid chart uh to see if there's any organ failure, for example. Uh And see if yours are working uh to see if they're really overloading. Uh So definitely uh should be like a senior decision. Uh We can also give some symptomatic treatment uh like paracetamol, acetylcysteine. Uh We should put them on regular nebulizers and P RN nebulizers. Uh And they're also can give them the regular inhalers if you see, you see that it fits to start them. Uh the oxygen target should be 88 to 92 in this patient because he had type two respiratory failure and the CO PD uh we usually start with a venturia like 24% or 28% depending on their response and on their oxygen needs. Sometimes we will escalate to an IV noninvasive ventilation, something like a bab. Um we will talk more in detail in the CPD lecture about N IV. But if they're not responding to uh venturia and to like nasal cannula, like regular oxygen and if they're, they still and type two respiratory failure and they're deteriorating, they might need N IV. Again, talk about feeling of care for this patient. Um probably will need uh DNA R uh because of the comorbidities, elderly, uh unwell, the, the, the CBR and heart failure co BD patients would probably not be successful. Uh And again, VT E prophylaxis and comorbidities should be considered. Can I just pause you here before you move on? Sure. Um I want everyone to memorize point number four. So any patient comes in with pneumonia, you always do virology, swabs, uh sputum culture HIV screening and the atypical screen, which is the urine antigens. That's for every single patient that comes in with pneumonia. Yeah. Yeah. And then with regards to the fluids and diuretics, I think just to summarize it, um giving fluids is obviously dependent on the patient, whether they are clinically overloaded. Um and giving diuretics is dependent on the BP. So if their BP is too low, you might not be able to give them diuretics even if they are clinically overloaded. Um and fluids obviously, you don't want to give fluids if they are already very overloaded, but you might be able to give them a very small amount if they are septic. Um So I think with fluids and diuretics, I think if you're not comfortable with prescribing any fluids or diuretics, I would just put it in the plan and just put discuss with senior and then just have a chat about it with, um, a regular or consultant because, um, at least you're not going to end up doing the wrong thing. Um, but you can just take advice, use that to sort of learn from and hopefully you get more confident with it in the future, but it is a bit of a sticky one because giving diuretics is very dependent on BP and giving fluids. Obviously, you can't give fluids to so already very overloaded. Um If if you write it in your plan, at least your consultants and reg straws will know that you had a think about it and just have a conversation with them, tell them what you think and use it as a learning curve like a learning experience because you have to eventually start making them decisions. So, yeah, I think it is really um OK, this is overloaded um from your examination. Uh So how will an over loaded patient in your opinion? I think he means with regards to this specific case, I think he had fluid in his lungs, didn't he? Yeah, and he has a background of heart failure. Ok. So this chest X ray you'll see this chest X ray a lot in your practice. So that's overloaded. You can see how the lungs are hazy. You can see how the hilum is like bulky, like easy. Um And you can see like post lines that extend like to the outer part of the lung. Uh and also the effusion, you also sometimes see that in overdo the patients clinically, they will have edema on the lower limbs, sometimes even the upper limbs. Uh and um the cation, bilateral basal cations and the orthopnea. All of those are signs of overdose. It's, it's mainly like a clinical judgment thing. And from the chest X ray also and from the history, the heart failure and uh reation, it's not just one thing, it's everything together all together. OK? And the fluid shot if uh you need input output monitoring for patients. Um it's usually heart failure patients if they have a catheter in or they have got an AKI because you need to monitor. Ok. They are losing in heart failure patients if they can and same with AKI because AKI treatment is giving fluids, isn't it? So just remember for them three input output monitoring. Um that should be a part of the plan. And then when you're on the wards and you see these patients, you have to check the input output chart to see um how much fluid they're losing, uh how much weight they're losing in heart failure patients, how much uh urine they're passing if the is working and just let me other. So that is very, very important in septic patients because even if they didn't have any comorbidities, sepsis on its own can cause organ failure. It can cause AKI and acute kidney injury and that can cause them to cavity. So it's very, also like very unwell patient patient. Yep, that's it. Ok. So that was um the fluid here. Like I know it's um maybe a little difficult, like it will be a senior decision. Usually in septic patients, you start fluid resuscitation immediately, but sometimes it's just not that simple. That's why I added this case. Uh because we see a lot of mistakes being done regarding fluids. Sometimes fluid are not given for patients who need them for patients who are um maybe dehydrated, going into sepsis and they're not given fluids immediately or the other way around given fluids and actually causing them to be more overloaded. So always um use your clinical judgment, always assess the fluid balance of uh or fluid status of a patient and that can be actually difficult, but you'll get used to it from seeing many patients from looking at a lot of uh chest x-rays. So I know this reading chest x-rays um might not be the simplest task ever, but uh your eyes will get used to them. You'll pick, pick up an overload on chest infections or whatever. Um And it's always very important to know the fluid state of the patient before starting them on fluids. Ok? So if we're happy with that case, say their BP is low and the patient input output shows basically no output. OK. So that's, that's an ICU patient if they're anor like no output. Um OK. So that's a little more advanced if their BP is low. Um And they have no output. That's like a very severe, that's basically will be septic shock, not just sepsis. Um uh I talked in the beginning uh the difference between sepsis and septic shock, like when would we say they're in shock? So you can start them on fluids if they're not uh overloaded. But if they are uh you might give something like a vasopressor uh like an infusion of norepinephrine, for example, but that will not be a ward level, that will be ICU level. Uh and steroids can also help with BP. Our target for BP is a mean of 65. Um If we can't achieve that with fluids, they will need vasopressors and they will need like higher. So that's why it's very, very important to talk about feeling of care. So of this patient, like if we did everything and they still have a low BP, they're still unwell. Will they be for ICU for further management or would they only be for ward? And like if, if they continue to deteriorate, they might initiate uh eventually need to have like dialysis, for example. But that again is a higher level of care. Um So on only wards. So for this patient, like this specific case, they will probably be only for ward because they're elderly, they have many comorbidities. Um There prob probably the CPR in heart failure, COPD renal failure patient will not be successful, it will not be in their best interest, it will just put them through unnecessary pain. Um But if like in a different case, uh if they are for escalation, if they are for ICU, they should be escalated. OK. Was, is it clearer now? Ok. So that was our third case. Now, I will briefly mention neutropenic sepsis. Um and we will quickly recap after that. So, neutropenic sepsis is one of like the condition that definitely should be treated by a specialist or at least a registrar. Um but you might be clerking one of them, you might uh be escalated, one of them or just be at the ward and you have a neutropenic sepsis. So, what is neutropenic sepsis? It's um it's a life-threatening. It's a very, very bad type of sepsis. Um It's usually in patients who are on anticancer and immunosuppressive treatments. Uh they might have a temperature of uh 38 or above. Uh they might have any ss signs and sepsis, uh signs of sepsis. So, uh they might have a cough, they might have um like symptoms of uh uti infection, symptom of um chest infection. Uh but on their bloods, the neutrophil count will be 0.5 or lower uh neutropenia or a neutropenic infection uh as opposed to sepsis, it will be less than one. Uh But anyhow, uh neutropenia uh yeah, will be um a low neutrophil count in a patient who has infection basically. So, um if neutropenia is suspected that should be um should be acted on promptly. So you don't just treat them at their news level, you would treat them more urgently more promptly. You would escalate as the higher uh grade of news. So if you remember the news uh score, like in the very beginning, we said if they have any like worrying signs or if there's any anything that we can escalate to a higher level. So, neutropenia is one of those things, one of those things that you should it be treated as a higher news level. So who is at risk of having neutropenic sepsis? Uh Usually patients who are on chemotherapy within six weeks of starting their chemotherapy uh patients uh on any type of immunosuppression therapy. Uh hematology patients, hemato hematological malignancies, autoimmune patients. They usually have a high temperature of more than 38. But remember, it doesn't always have to be the case. Some patients who are shocked will have actually um a lower than normal temperature, they might have diarrhea, they might have symptoms of infection, ri uh whatnot. Uh sometimes the source of infection might not be clear. So they might have a fever for example. And you don't know where the infection is coming from. They don't have fever, they don't have the, uh I'm sorry, they don't have cough, they don't have diarrhea. We call that uh fever of unknown origin. Uh And those patients are particularly difficult to deal with. Uh and you have to do a full sepsis screen on them. Uh So usually a full sepsis screen includes uh blood cultures. Uh and preferably before you start the antibiotics, it includes a urine culture. It includes a sputum culture. And if there's any other source of an infection, like if there's any wounds or if there's any devices, um like a central catheter or any devices that they have. Uh you can also get a culture from that you can get a swab from it. Um full bloods should be done. Uh blood gas should be done lactate level. Um You should also do a chest X ray. So when we say a full sepsis screen, it's, it, it basically means that you will because you don't know where the infection is coming from, you have to do uh the investigations of the most common sources of infection. So uh what do you do with people with neutropenic sepsis? So it's like normal sepsis, but you have to be more careful with them. You can refer them to the oncology team if they, because most likely those patients will be um cancer patients on chemotherapy or if they have like a hematological malignancy of any sort. So you will refer them to the oncology team and it's very, very important to put them on a side room. Barry a nurse in a side room because they're very, very vulnerable. Um They can deteriorate rapidly. You don't want them to be exposed to more uh pathogens. Uh fluid balance shot is important. Uh We um talked about it and we said why it's important, uh observation should be done at least four hourly, if not less, usually less after a, if they have nic sepsis, um you will contact the critical care team if they are for critical care. If they don't have like a see of care, you should uh escalate and talk to them about the patient even if they haven't deteriorated yet. But like they can deteriorate very rapidly. Um try to avoid using antibiotics with these patients because as I mentioned, sometimes they're not even feverish and that can be actually worse than having a fever because they might be in severe shock that they're not feverish. Uh But because antibiotic can mask the signs of uh infection um and avoid doing pr examination because again, that can be a source of infection that can introduce unnecessary pathogens. Um If they are um solid tumor patients, uh you can give them something called Grote Flein. Um So that's, that will be uh prescribed by uh a specialist. So you don't have to worry about it, but just uh maybe be familiar as with the name. It's a medication that um induces the production of uh neutrophils. It stimulates the bone marrow to produce neutr some patients, we give them that in neutropenic sepsis. Um and contact hematology if they are hematology patients, like if they are lymphoma patients or leukemia patients, for example. Uh So just to quickly recap. So, neutropenic sepsis treated as regular sepsis, but with extra care, like putting them in a care room and um referring to oncology or hematology uh and avoiding introducing any unnecessary pathogens. So, um this is an example of what antibiotics we can give again, always, always follow your local policy. So for things uh like fever of unknown origin, we can give something like um gentamicin, metroNIDAZOLE um and uh amoxicillin for things like uh fever of unknown origin, like uh piperacillin tazobactam always just follow. It's um you'll find a policy for anything. Ok. So uh Iam just asked when you say to do four ops per hour. Is this shared with nurses or soly, the phone jobs? Oh, no. So observations are usually done by the nursing team and uh four hourly means every four hours, not uh four times per hour. So every four hours they would do ob observations is everything like um heart rate, BP, temperature, respiratory rate and oxygen level. Ok. So just to quickly recap, I know we covered a lot of things in this, in this lecture. And I didn't even scratch the surface of sepsis. It's a very, very big topic. Um But the take home message that you should get from this lecture is the escalation. So we talked about um went to ES to an F one, went to ESCL to sit and went to ESCL to a registrar um and the ops monitoring. So any patient with sepsis monitoring is very important because they can deteriorate very, very rapidly. Uh So observations and how often you do the observations depending on their new score. Uh Usually nurses are very aware of that, but um some of some nurses are new or they don't know. So you should also be aware of that when a patient has escalated, you part of your plan is should be like every one hour or s every four hours, whatever you see suitable, uh part of the monitoring is the urine output to the fluid chart. Uh They can give you uh a hint about organ failure uh and dehydration or overload. Um state of the patient. Uh You should do full bloods even if the patient like had bloods um maybe a day ago or two days ago, but they're now deteriorating, they're now um scoring higher than they used to. You should always get a new set of bloods, including a clotting screen, including a blood gas. Um And, and if the hemoglobin is low, they might need transfusion. For example, you will see uh look at the white cell count, the ph the lactate crp uh oxygen target. We talked about scale one and scale two and fluid resuscitation. That is the most important thing. It should be timely. You should always, always not delay the fluid resuscitation, uh always start with the, the bolus fluid. Uh and we talked about VRS and steroids. Uh but that is for a higher level of care. You will usually not uh see patients with vaso BRS unless they're in icu. Uh antibiotics should be timely. It should be within one hour. If they're using uh a seven or more antibiotic should be started immediately. It does not much matter where the patient is, start him on antibiotics. Now, uh source identification is very important from your history, from your examinations, from your bloods, from your scans. You should I be able to identify the source. If you're not be able to identify the source, you should do a full sepsis screen. So a full sepsis screen uh can include blood cultures, u urine cultures, sputum wound cultures and swabs from any devices that they have. Uh and source control according to the source, sometimes it's surgical, sometimes it's only antibiotics and medical treatment. Ok. Does anyone have any questions? So I will bring back the case that we started with in the very beginning. Uh the patient who had the double J stent who apparently has an infection. Now, uh and I want you to try to um write the plan again for the same patient. Can you write down in the chart? What, what do you think? Now the plan should be? So, initially you mentioned a few things which I agree with, but uh are there more things that you think we should do now write down in the chart? Anything you, you think? No, OK. Bloods. Just x-ray E CG fluids. Yeah. Uh What do you think the source of infection is for this patient? So apparently they're using a six uh they're a little feverish, their left. He is high virology, swabs. OK. Um Diuretics for urine output. OK. Why do you think this patient has decreased urine output? So, yeah. So does he have post, that's a very good point. So this patient, he has a, an obvious source of infection uh which is the uh the stent, the double J stent. Uh it's a stent in the ureter. Um And uh they have low pain. So it's the probable cause of infection is um urosepsis or bone nephritis. Uh The because of AK I can be uh post renal uh like uh it can be blocked maybe. Um but uh usually it it should be bilateral to, for them to have a decreased urine output or if they have like a solitary kidney. Uh and it can also be due to the sepsis. The sepsis itself can cause an AKI I say man said, does he have an AK I it could be. So uh we should look at his um uh renal function, which is, which are not mentioned here. So that should be part of our plan. Why does he have a low urine output? So we should have a close monitoring of the urine output fluid chart, maybe um uh a bladder scan or even a catheter to mo monitor the urine closely. Uh And we definitely should get a scan to identify the uh the infection. So uh no one mentioned the B double J. So it's surgical to correct to remove. Exactly. Yeah. So this patient has an obvious source of infection. We can give them fluids, which is very, very important. A bolus of fluids uh and antibiotics. But again, he has a source of infection which will uh not be resolved just by giving fluids. We should uh refer to urology immediately. We should discuss that with the urology. Yeah. Lenin. Uh very good. Yeah. Um and uh they should also get a scan. So uh someone mentioned that do they have like a postrenal uh like is that what's causing them to have an AK I or is it prerenal because of the sepsis? They should definitely get a scan. Um an ultrasound or a CT scan. Uh It will show if they have uh hydronephrosis. Uh that means that there is a block or bi nephritis. Uh that's very, very important also in this case. So in this case, he's using a six, but we will treat them as a higher because they have like a treatable cause like a surgical cause. So we should give antibiotics within one hour. We should give the fluid bolus, we should clo closely monitor the urine output. Yes. Iman Yes, very good. Uh Escalating you seven within three hours. Call the surgical team and arrange surgery. Yes, that's very good. And I know the time scale is like, um it's not very realistic like in real life with everything in the images like and they're very notorious with their like waiting times. Uh But you should definitely recognize the more unwell patients and re prioritize them uh and try to act in a, in a timely manner uh especially with the fluids and the antibiotics um and earlier referrals. Ok. That's very good. I think you mentioned all the important uh points in this case. And what do you think the feeling of care should be for this patient? Do you think uh we should have ad or not have one? Yeah, he can go to ICU. I agree you ma'am. So this patient uh is young uh no comorbidities other than uh the double J stent that he had. Yes, young doesn't have severe comorbidities and it's reversible because of his sepsis is reversible. If we remove that stent and if we give him the appropriate antibiotics, it's reversible. So that's very important. Um Just to keep note of that. Ok. Thank you. Everyone. Does anyone has any questions about anything we discussed in this teaching? What are the feelings of care? So yes, were you with us from the beginning of the lecture? I think we mentioned them a few times. Ok. So a ceiling of care is basically um what the patient um ceiling is. So a ceiling can be at ward level. So that's the maximum care that they will get or they can be higher, they can be something like ICU. Uh it's very case dependent. So in each case that you clerk, uh you should think about that, is that patient for escalation? Because what if the patient deter further? So what if this patient with sepsis went into septic shock? For example, like will they be moved to an ICU or they will remain at the ward? You should decide that very, very early when you're talking every each and every patient. Uh and that plan should be in place. We will talk about seedings of care again uh in the elderly picture and we uh Anisa talked about them uh in the very first lecture. If you haven't listened to it, I highly recommend that you do. OK. Any other questions? Uh The first lecture is recorded um we can share the link in the group. Um Not so I think it's on meal. So if you just go on the Conquering Residency page on Metal, you find a recording of the previous lecture. OK. Yes. Thank you. You guys, I think you did really well with the plan. Um I've been sitting in the background looking at the chart and I think there's definitely things that you mentioned at the end that you never thought about at the beginning. Um So I can see that improvement and I think you did really well. Um What else do I need to know? Uh Thank you for joining. And when you guys do the feedback forms to get your certificates, please mention in one of the boxes, a few things that you learned from the session that you didn't know about before because that'll help us with the future teaching sessions. Um, and then definitely, like I said previously, keep a collection of the certificates that you get from the teaching session and just put them in a file because when it comes around to appraisal, you'll have to do one quite fast when you start working because I think the first appraisal isn't done with in the first year of working, it's done as soon as you start working. Um, so if you put them upload them certificates, it just, it's used for your CPD S and it show that you're competent and you're using your time to study and, um, work as a doctor. So definitely put all your certificates together in a file and then you can upload them for your CPD and for your appraisals for, uh, your appraising to go through. Um, if you have any questions, just message on the chat or, I mean, the whatsapp group chat or just message me if you, if you don't want to message on the chat. Um and I think the next time we see you will be next week and we're starting with cardiology. So we'll, we'll start with the common presentations you see in cardiology. And essentially, it will be the same format whereby we go through a case and we'll go through, we'll go through, um, plans for sort of those presentations and then hopefully when you start working or when you're at work, you'll be able to put these plans together a lot better than I did when I first started working. Um, yeah, I definitely like to write it down. So, yeah, continue, definitely write down, um, like a generic sort of management plan for sepsis. So, anything that you've learned from today, um, just write it all down so that you have like a record of what to do. Um, and what sort of investigations you want to order, uh, just a bullet point list so that you can go through it in your own time and it's just easy for you to refer back to when you start working. Yeah, definitely sepsis is one of the very important for me. It's a very important topic to cover in time. But I think you, uh, got like the main, all the things, uh, and you'll be more familiar with the uh go through the sessions by the end, you'll have like a good, a good chunk of management plans for a lot of the things that you see in the hospital. So whether you're on the ward or in A&E you should be able to know how to manage them. Um And to save you from using your own time to like go through extra medical stuff, I think whilst we're doing the teaching, just write like a little list. Um Yeah, management plan presentation. And then when we get to the end and we ask you to review the case that we talked about initially, you'll be able to sort of pick up and, and put in extra things that you weren't able to mention initially. Um I hope I found it like when I first joined because working in the or in the UK could be very different from other countries, things like things like um the like the VT like uh it's very important to do in every, each and every case. Um Make note of like the new things, the things that you weren't familiar with the, the things that you learned. Uh I actually did that once I started working here because um there are some things that were not used like we just like every place has uh it will be very for you when you start walking. Um Someone is mentioning the whatsapp Group Chat. So I can you, I'm not sure. Yeah, I'm not sure how to, um, send the link. It's a, it's a group chat of all, all the pa, all you, I think they mainly like m students, um, for the teaching session and we'll just sort of announce, um, the dates and the times that we're doing. If you send me your email, I'll be able to sort something out so you can just send an email onto the chat now. Um Oh yes, sort it out, Iman if you're still here, I just wanna say that I am so proud of you. Uh You answered quite a lot of the questions and I think you did really, really well. Yeah, and your plans actually very improved at the end. You uh I really liked your plan in the case in the end. Does anyone else answer the questions? Are you back in the UK? Are you still in? Perfect. Thank you for the email. I'll sort something out for you. Um Iman, congratulations. You graduated and also to the other people that are in the chat that recently graduated. Congratulations. And I really hope we can make into the NHS easier for you guys. Um Definitely take on board everything I've said in the last few minutes when you do your attachments, Iman and everyone else in in the chat. Um When you do your attachments, I think you your best shadowing will be with the oncall team, uh shadow the sho that's clocking patients in A&E they will be seeing patients and doing management plans just like we're telling you now. Um And because your doctors, you can take patients and see them yourselves. Um and just do the clocking yourself. So that will, that will help. Um If you see any, anyone that's sort of got any of the presentations we cover in teaching, like we've done sepsis now. But if you've got a septic patient while you're on attachment, they've come in with a UTI or whatever it is, have a go at it and try clocking them and you'll have that support with the sho and uh the reg like if you have any questions, you'll be able to ask them. But that's one way you can work on, on your management plans and also like shadow the um sho that's on the ward as well because they'll be getting bleeped for unwell patients on the ward. So you can go with them and um sort of examine patients that are unwell and order some tests that they need put in the plan. So you'll be able to see if you haven't seen the previous um session. Have a look at it because I do mention how to properly inform a document when you're on the wards as well. Um It's really, really important that you document, well, especially if there's a complaint later down the line or the patient dies or something happens that goes wrong. Everything needs to be written or typed up. So definitely shadow the sho that's on the ward. And the one that's clocking have a go at clocking yourself, that's how you're going to learn. Instead of just sitting there and watching them clock, we will definitely make your own plans and then, um, just run them by an, by someone else and, um, maybe see when they post taking by a consultant and see like what, how much of your plan will continue if there's anything that you miss. And that's, that's a good way to learn. If, if you've clocked someone, uh you can just later on once they're seen by a consultant, you can have a look at what the consultants written for the diagnosis and the management as well. Uh, just to see what areas were missing. Um But definitely try and do it yourself because you'll have all the support when you're on attachment and you can have your plans run by other doctors. Um And the sooner you start doing it, the more competent you'll be. And as soon as they see that you're competent, the easier it will be for you guys to, uh, start working and get a job in the NHS. But thank you for joining. Um If you have any other joining, please don't forget to the feedback. Yeah, definitely write the things that you've learned that you didn't know about before the teaching, uh because that will really help us guys as well. So Thank you guys. If you have questions, we'll, we'll stay around for another like two or three minutes. Uh But I'll let you guys go. Thank you. Um So in the recording you should have, uh the slide should be in the recording. So you're able to just go back to the recording and just see what anything that we've mentioned that wasn't in the slides as well. Um Can you feedback? Um Usually when you finish the talk, when we finish, um it should be hang on. Yeah, I've got a link for it. I'll just put it in the chart. OK. That's perfect. Thank you for reminding me you can leave it also on the whatsapp. In fact, um it might be easier if I just send it on to the whatsapp chat but then you guys need your certificates. Hang on. OK? I can share the link to you. What's in here. Yeah, I in the group, I'm just trying to, if some people aren't on the whatsapp chat, then it's just easier to Yeah. II shared the link to the whatsapp group. If anyone that is who is not in the group. Oh, is that for the group? Yeah. And we'll share the link to the uh right. My I share the link to you. I can show it to you. Yeah, because like I can't go on my whatsapp on the laptop. Actually, it's working. Never mind it's working. Mhm. If you want, you can just send it to me. Hello. You? I know that your certificates do save on medal but definitely keep them in a file as well because I did a lot of my training stuff and I didn't save the certificates along the way and I ended up not having certificates for my appraisal. Uh, so just save them in a file anyway. Ok. Um, let me see, um, broadcast now and if anyone has any questions, they can be in the chat and in the chat also.