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similar to kind of varicose veins. Um, that is in the testes so often. When you're painting, you can know if that's the reason of pain and also a hydrocele, where you can just get fluid. That can sometimes happen. Um, if it's a dermatitis but often just shine a light, and that can be reassuring as well to look through in terms of hernias, they can very typically cause referred pain. So make sure you get the patient to stand up. Make sure you get the patient to give you a good cough. Um, they can be your kind of non testicular referred pains. Um, but you want to check if there is swelling, especially in the inguinal region. You can often get really big hernias that make things difficult to see, and everyone's anatomy is different. So if you're not sure what you're looking at again, this is where you'll be calling your surgeon, calling your senior just to make sure you're a surgeon. Um, if you're worried about hernia, then you can get a general surgical consult. You want to see if it's reducible or irreducible, incarcerated or obstructed because they are the patients that will often require to go to theater with your general surgical team. So with caution, you have, um, it's normally stressful, and it's an emergency because there is a six hour window where you want to get your patient theater. So that's why um, you want to if you get called to see a patient with a swollen, painful testicle, you want to prioritize these patients, really, especially because they're often young and you want to be getting your senior involved as soon as you can. Um, just to make sure that you if they do need to go to theater, you have somebody who can do that because you as an f i t Unfortunately, you're not there yet or 54 or until you've done your surgical job. So basically, um, it's I'm sorry to do something here. You've just got this flow diagram, which is from the guidelines as to help you go through. So you've done your history and examination. Um, if you're worried about torsion, you just get that your urology senior straight away, because they'll need to go to surgery within six hours if you're a little bit unsure. So things that might change your diagnosis will go on to. But if there are signs of infection of cellulitis, sexual health, strong history of unprotected sex and you're worried about ST I, um you've done a urine dip, and it's a really strong for infection. Um, it's kind of been a gradual onset. You're not sure? Then you. And if you've got time, you probably discuss this with your senior first, and they might ask you to request a scrotal ultrasound so you can get a Doppler. Um, and that can just help you show the blood flow, um, to work out whether this is somebody that needs to go to the theater straight away. But I wouldn't ever request an ultrasound and sit on it because that's wasting time. So just make sure that that's come from your senior. And then, if you are organizing the ultrasound, make sure you call the team, make sure they know it's a priority. Make sure you know where your patient is and when they're going. And the times you just say that you can update and be on it and chasing that report as well, because if they have got attention, they need to go to surgery or if you're querying it, they have an orchiopexy, which is basically where they untwist and the testicle to restore the blood flow. And we'll stitch it back to the inside of the scrotum so often they will do the other testing as well. That's not being tortured testicle as well, just to make sure that they there's no recurrence. So the worrying thing is, if you delay that testicle can become necrotic, you can lose it. You might need a, um, prosthetic replacement or just left. So you need to. The longer you wait, really, the higher the chance it is that that test might have to be removed. And and I think that's everything that I want to mention. We will revisit a little bit some other factors which we can go through. Um, but I think that's all. So just quickly something's not to miss, which we briefly touched on. So epididymo-orchitis is your very, very common differential for testicular pain. So just make sure you ask, um, you inappropriate about sexual health history Patients having unprotected sex? Um, it can be more common in, um, if there's to get diarrhea and UTI symptoms, you can get pain from the tip of the Penis or penile discharge. Often these patients can have a more effective picture where they can have fevers or rigors, might want to do blood and do an effective work as well. And they may be more gradual, more gradual history, so you could get gradual swelling or pain. But they still are sometimes a unilateral, which makes it difficult to differentiate. And these patients will also often have a red hot, swollen hemiscrotum. So it's just, um, important to examine as well and typically less tender with your friends test, as we mentioned before. For these patients, you want to do, um, an M s your first captain in midstream to send off for your sexually transmitted infections as well. And also, you'll often do a swab. Um, so again, another thing is for me is gangrene. Um, it's basically really important not to miss, and that's why when you're doing, your examination is really important to check as much of the skin as possible. So this is where you can get, um, black and necrosing, basically like a cellulitis that's really advanced, and it's often over the perennial region. It can start from a prosthetic abscess. So you'd want to do a rectal exam just to make sure that that's not a boggy prostate. And you check the perineum as well just to make sure that there's skin. There aren't skin changes all the way around. Um, but if you're just having a quick look and you're in trouble, you're not suspecting it. That's fair enough. But if you're worried about some skin changes, just make sure you've done a really good look. Um, lots of skin. And there's not a necrotic area that's hiding from you. And in terms of, um, it's really important that if you diagnose epididymo-orchitis, you're you know you're happy that it's not, um, torsion. You had the ultrasound, you started them on antibiotics. They often have an I am dose, and then we'll go into the orals. But just make sure that these patients get a follow up ultrasound, they say with them one week. But often you can just write on the discharge letter to the GP. Um, this is really important to have, because 10% I think there's the staff that any one with epidermal colitis often it can present as an infected picture But they may have underlying testicular cancer, which has been put down to the, um, inflammation. And it's really important to get that follow up ultrasound just to make sure that there's no cancer that's being missed. Um, I think that's everything I want to mention about torsion, but we'll come back to it. And obviously you got any questions. Feel free to write them down. And okay, so now we're going to go into urinary retention. And with that talk about capital is because the to come beautifully hand in hand. So urinary retention again is something that you will see. Um, even not as a urology. You'll just see it everywhere on the ward, any D. It's very common in hospital because, um, often it can happen because it changes in medication of operations. Um, sometimes because of infection. So this is something that you might get called to see if another team need help with it. But you will. You'll meet this inevitably in your war jobs as an F one f two. So just some reasons why people can go into retention, um, structural reasons. So, actually, my acronym for this was spin. Um, but I forgot about medications. It doesn't quite work, but it's good to think about spin with an M and so structural reasons. BPH Benign prostatic hyper petro fee is a reason that can cause, um your attention, which is really common. And this means that patients are going to catheterize. But if the prostate is enlarged, urine can flow through, and these patients can go into retention. So another reason to do a D r e um, if there's a pelvic mass, um, more worryingly, but in, um, if it's cancer, But you can also get a large fibroids or you're a guinea presentations where you have to do an ultrasound just to check for anything that's compressing and causing retention. You might have a patient who has significant hematuria, and they can get a clot, which gets, which causes the obstruction and go into retention, which is clot retention. And that might be after a procedure or again, with some bladder cancer patients. That's something very common. Um, with stones, a stone itself can be enough to cause retention. Um, so again, that's something to look out for. You can get, um, an inclusion further down the line. Paraphimosis. Um swelling often after, um, capitals been inserted. But the force that hasn't been replaced you can get a, um paraphimosis, which is inflammation of your force, the tip of the head of the Penis. So that's something to look out for. And the best thing that you can do is if you find the space, and the first thing you do is make sure you always replace the force community, a capital which will come on two. But that might need, um, compression, so we'll come into that a little bit if you see it. But that might be a reason why the patient isn't passing urine, so it's always good to check. We talked about cancer and also constipation so really common in your elderly population. If somebody is significantly constipated, um, or they have other cancer potential complaints. If you go back to a lecture to some vision, um, that could be another reason. So again, another good reason for doing a d e r e um, postoperatively. You can have either a urological procedure or general anesthetic for pretty much any other, um, surgery. Often people will leave a catheter and or if it's taken out, too soon, then they can be retention. Infection can often cause it. And also some of the types of medications opioids, anti cholinergics, anti histamines antimuscarinic. Um, and so those medications, especially where it can't see, can't be, um, I'm not a lovely acronym, which I'll drop down. But that's their your drug side effects, which often are good to check and also something that you always want to rule out. So do a thorough neurological examination because you don't want to patients who have back pain, potentially cord, a recliner or spinal cord compression. So just make sure you've tested the sensation and make sure that they don't have any saddle anesthesia. Another reason for doing a d r E just to check tone. And make sure you clarify with the patient, um, again, because you might want to ask them to, um, you know, actively clench down while you're doing your dairy, just to make sure that there's no loss of tone and no cord required. Because that can be another reason why patients going to your attention, which you do not want to miss and then some other neurological complications as well. Um, but yeah, I just thought I'd run through that because there are so many reasons why patient can go into retention. And it's just often, um a how they present and important to just make sure that you're not missing anything else. So in terms of signs and symptoms, often it's very, very painful. Were only supposed to have between 406 100 mils in our bladder. So, um, if you're having a lot more your bladder undistended and the biggest again very a patient be crying out, Um, and it's important to a bladder scan just to see how much is in there. Um, they may have a low urine output, so I've not been producing urine for a little while. Um, they might be confused and constipated in our elderly population again. You want to just check if they have got long to grow in pain. Um, that there's not a stone that's been missed getting that. So, um, your typical investigations again as we go through nothing. You just make sure you dip their urine and and sent it off if needed, um, to check for an infection. If they have a catheter in already. You just want to make sure that you put that on the form and these patients will need a bladder scan. So you want to know how much is in their bladder just to make sure that that might be a reason for doing a capita. If they've got too much going ahead, or if there's not that much, you might want to think of pre renal causes. Why they're not producing urine if they have a low urine output. Um, in terms of your PR, your rectal examination, as we've talked about, I can't stress enough to you how normal these will become and how used to it you'll be doing. You just have to make it part of your abdominal examination. Add on really just to check for the prostate, check their neurological, um, sensation and tone. You can check if they're constipated. Um, they're all really useful things, and it's a really quick and easy way just to make sure unpleasant for the patient. But it often could be done just to make sure that you're helping that with your differentials. Um, if you send off some blood, you might want to think about again doing a use, and he's checking. They're not an a k I, but also if it's a bladder outflow obstruction, which didn't actually talk about the previous, um, sense in terms of cancer, you might want to check the prostate cancer as well, which will be your PS A. And that's not necessarily something that you would do without a senior discussion. But if a patient is presented and they've got urological consult, and that might be something you consulted, want you to ask on and ask you to add on just in case. And then, um, these patients may need an ultrasound, especially if there's a backflow, um, and a CT KB again just to check for any structural damage. So with an ultrasound that can check for hydronephrosis. Um, and that's, um, something to look out for, especially in your high pressure retention patients, which will come on two. Been through all of these differentials many a time, but just important to keep a broad mind while you're going through it and briefly want to talk about high pressure versus low pressure retention. So, um, in terms of your high pressure patients, um, these ones will be the ones that come in acutely in pain they normally have more than 1000 miles in their bladder. They have signs of a K I, and also they have a backlog, so they have hydronephrosis for these patients. If they've got a catheter in, you can't just take it out and hope that your problems will be fixed, unfortunately, because they will just go back into retention or, worse, that back pressure on the kidneys needs time to settle and to solve. So the capita is a treatment for that high pressure retention to make sure that they don't get further scarring and damage done to the kidney. Because if you take that catheter out and they had more than 1000 miles in their bladder or they're in a K I or they've got hydronephrosis. Unfortunately, you'll just create the same problem again, so these patients may need a catheter in for a little bit longer. If it's low pressure, attention and you've got another dimension of why this happened and you fix that and there's no hydronephrosis and that there's not an A K, I give these patients IV fluids to help manage them, especially if their kidneys have been knocked off a little bit Um, and the tamsulosin is really helpful again. That's that smooth muscle relaxant, Just in case. Um, there's some irritation. It can also be helpful getting technical apologies. Um, so just briefly about retention. So if they were a high pressure and they failed their trial without the capita, so that's what's called a to work. Um, they may need neurology. Follow up so patient will go home with the capita. And you need to make sure, as part of your discharge letter and your discharge, plan their book to come back in, um and often see a fabulous team of urology nurses for a trial without a capital in a couple of weeks. So they need to go home with a capital care package and they'll basically come back into a trial void and check that it's not urine left in to make sure everything is resolving, um, to go back. But if they are failing that, then they may need a long term capital or a super pubic capital, which will come on two, um, or something like a terp again, which will come on two, which is a treatment for BPH. Um, so with going home, if they're going on for two weeks. You give tamsulosin, which is your alpha blocker. And that can help relax the prostate as well for those patients. Um, so yeah. Okay, so now, just before we have a break and go into our case studies, I'll just check Howard in for time, and we will. I'm just going to briefly talk about catheters because they will inevitably be the bane of your life as a urology junior. So, um, briefly, we've got our standard catheters, Foley catheters, which often to way we've got a three way catheter and a super pubic are the common ones you have. Um, so, um, they were just over the indications of when you might need them. So urological reasons might be your attention. It might be acute. They might be post surgery. They might have just been a joint or a whole that's made. And it might be needed for drainage after that to help the tissues around it heal. They might have recently had an anesthetic, which they need a capital. In medical indication, they might not be a neurological patients specifically, but they might have one in because they've had been very unwell. So we're monitoring the urine output. Um, if they've been septic or is there an I see you, they might be very frail patient, an orthopedic patient that's had an operation or unable to mobilize to the toilet. So they've had a capital put in for that time. Um, so just important to work out when you're dealing with the capital, why it's been put in in the first place. Um, and also, if they might need one, might fall into some of those categories. So with your standard capitals, they have your whole for draining out the urine and also a place to insert your 10 mills of water, which is how you inflate the balloon for the capital. Stay in position. Um, I cannot stress enough that this balloon should never be inflated until you see you have proof that the urine is draining out because you can put the catheter in. It can go in easily. You can feel that it's okay, especially if your patients on Well, you want to see evidence of the urine coming out before that balloon is inflated, and we'll go into some tips to make sure that of ways you can get to make sure it's draining, but you do not want to be inflating that time and 10 mil balloon anywhere. But when it's in the bladder, and if you're not getting that visual reassurance that there's urine draining out before inflating that balloon, I'd be escalating just because of the damage you can do if your inflate balloon the patient, if they're awake and happy, they will be very unhappy. Should be telling you because it'll be immensely painful. Um, but it's just something to be very wary of. Um, so in terms of just briefly about sizes, I think men, male and female capitals are now all the same. They're just different ages. So commonly, um, they're all the same length. You used to have short, shorter catheters, females and men. But now I think they're all the same, and you often will do a 12 French for a female and 14 French for a male. You will set up on your catheter trolley and have everything that you need to always bring two things that are still a gel. Just because you can never have enough that's your local anesthesia that you'll use. It will often help the urethra inflate as well. So that's one good reason. And then also, we'll give it a bit of time to help numb. Just always check somebody's allergies not only for the latex in the Capitol but also for the instead of gel has local anesthetic and some other products in it. So you just don't want to make a simple capitalization more complicated by giving somebody a reaction. And so that's about standard catheterization in terms of your three way capita. If you're inserting one of those you've been asked to, it's normally a little bit bigger and less flexible, which can often help prop up the structures, especially if you've got clots. So for a patient that's in clot retention, either they just recently had a, um, a operation to the bladder, where it's causing blood, or they are producing having him diarrhea with large clots. This might be useful because you can do a washout. So this has an extra Lumen where you can, um, put saline in either by a big syringe or, um, with drainage that can be on which can help irrigate the bladder. Um, and if you're asked to do a washout, you never do one unless you don't want before and have been shown how to. But your seniors, your britches will be able to take you through showing how to do a bladder wash out, which can help dislodge the clots and dilute the urine. So initially, if it's frank hematuria and bright red blood, you can do a washout. And how that have a nice rose color just to make sure that your irrigating and that that catheter is draining nicely. Um, with any capital, same as a chiari. You always want to talk about allergies, But you always want a chaperone. Never feel even if you can't find anybody, just wait until you've got somebody that can, more than anything, for medical legal purposes. You just need somebody else there with you. Um, but make sure you've gone through with the patient, explained what you're doing and why, um, and then have somebody there as an extra pair of hands, but also as your chaperone so that you can document in your notes, um, that this is who you had. Also, you're just always get an extra pair of sterile gloves because this has to be an aseptic technique you don't want to introduce infection and again because go through in your mind, especially if you're in the middle of the night shift, what you're doing and when to make sure you know how you're going to clean. Who's going to do what Between you and a chaperone or if you've got another pair of hands, help just to make sure that things stay as clean as possible while you're there. Often it's important again to do a P r N D R e Just to make sure that you have covered, it's just easier while everything's, you know while you're there. Anyway, just make sure that you've made sure you check their sensation. In case is fine sec or um, called recliner. You can check the anal tone. You can check the prostate to make sure that that's not a reason why they have gone into retention. Always, always replace the foreskin so it can be very easily you've got your urine straining back nicely. You're happy that you've managed to successfully catheterize this person very easy. If you're busy to just not think you just have it in your mind always must replace that foreskin. Otherwise you can get paraphimosis. And that's that thick band of edema, Um, that can sometimes even need to ischemia and compartment syndrome and just be so, so, so painful. And so that's the distal part of the It's like the tip of the Penis, the distal glands and that can become really, really swollen and inflamed. And then once it's gone, it's very difficult to then get that foreskin back. So just make sure you put it back and anyone who's doing one for you just check that it's being done, because if they are in power of the most is the easiest way to get that swelling down and get the foreskin back over is to apply pressure. Um, so you will often just use your hand, explain to the patient what you're doing and why, and squeeze for about five minutes as long as you can make great small talk. Four. Um, and just make sure because then once that Dean is settled, you're able to then retract the foreskin. Um, but yeah, it's it's better not to get into that situation in the first place. Definitely. So, um, we're just going to briefly on to some tips because you maybe being dealing with slightly more trickier capita than your other colleagues and other jobs so often. If you get called someone's attempted to do a catheter and has been unsuccessful. So, um, female catheters. Everybody has very different anatomy and just need to make sure that the catheter is in the right place. Um so often, especially as the vulva wars come more atrophic and, um, and as we can change as well get older, it can be difficult to see if somebody's dry and hasn't been drinking or passing urine. The urethra can be closed, so you often can't see where you're going. So it's just important to have some tips and tricks available to you, um, to help you be more successful. So I would often, um, just make sure you've identified your landmarks. It's very common that people attempt to that it's stoked about, and it's talked about so often that catheter is the clitoris. But just be aware of where that is and make sure you know where the vaginal vault is as well. Often, people say about putting a catheter directly in the vaginal vault so that you know where it is and you're not trying to attempting to catheterize the vagina. But you can, actually, sometimes either put a capital there or put your finger there and lift up and so that you create space and you might be able to see the urethra there and put in Sturgell before you go so that you can open up the structures. Um, you it's really useful to have extra hands for this as well. Just in case, um, there's a lot of cold or tissue just so that you can make sure you're visualizing because if you prepared to fail, you prefer to prepare you prepared for whatever you will struggle. So you just want to make sure, especially this is the time when you're on the night shift, get your lighting right. Get your positioning right. Have an extra pair of hands. Be ready so that you can make changes and adapt, and you don't get there and think I can't see anything. I'm not gonna be able to do this. Um, and then with men, it's just really important to get patient laying flat and you have a Penis up at 90 degrees anatomically you are going having to go around the curve, so you just want to make that as easy as possible. And you, um so you have just get that patient named flat use to instill a gel. One will help open up the canal, and one will. You can never use too much, really. It's not going to do any harm, so just make sure you've got extra there, which can really help to open the best you can. If you're struggling, you may need to use a curved tipped catheter, a Q tip, which you've got a picture of here. And that's where, Um, if there is a large prostate, um, or if it's been a difficult insertion, you have that slightly curved tip to help on your side. You want the tip to be facing up to their nose, and you know, if it's tricky and there's been a false passage made, this is where you'd be escalating to see if you're not confident yourself. But there are a few things you can do with positioning getting extra hands, um, to help you see if you can do this catheter first and practice as well definitely helps. So I'm just going to revisit this part about not draining because often a catheter inserted they've been dry. There'll be a reason why they had not waited to see your and until the balloons been inserted. But actually just make it part of your practice that do not inflate the balloon until you see urine draining. Um, basically, there could be a couple of reasons it might be that that some of the instill a gel is at the top of the capita. So you might just need to again what we said about the clot retention. You might need to just flush that capita to dislodge the instill a gel. Um, so you can get one of your big syringes and flush the capital to make sure you dislodge that you can get the patient, then this prior to make sure everything is hell in place prior to inflating the balloon, sit up to cough, increase abdominal pressure to try and get a patient to pass urine, um, or and make sure you got fluids running. Make sure you you know that they are producing urine. Get a bladder scan, see how much is in there. But if there's no urine, don't inflate it basically because you can really damage structures. And if the patient's not able to tell you they're in pain, it can just cause so many problems later down the line. I was just really going to briefly talk about Suprapubic Capitals. Um, before we have a little breather. So and super pubic catheters are done for those patients who were a, uh, normal capital can't be done. They're not for urethral catheterization. For whatever reason, whether that's because of trauma or they need a long term capita or pelvic injury, they will have an S p. C. As they're called. Um, these have to be done under ultrasound guidance, normally with a flexible cystoscopy as well to just check, um, anatomy. So this will be done by your age and above. Don't ever think that you should be putting in a suprapubic catheter, even changing them. Make sure that you've got your Reg there or a senior involved. Even if you've been asked to do it, don't feel pressured into it. Um, there's many reasons why these now done under ultrasound guidance, but they often want to check the structures when you're going in and with the suprapubic catheter with changing them The biggest thing is that they can close up very quickly, so you need to be able to stop them. Um, know what you're doing, and they're very simple, but you want to be shown how to. So make sure you've been shown and that you feel confident before attempting a couple of contraindications. If you've got coagulopathy. If you've got cancer, lower abdominal surgery or abdominal cellulitis, they might be reasons why you can't have proper suprapubic catheter in. Just to be aware of and also being an F one F two is a contradiction to put one in because we we shouldn't be doing it. Um, it should be for the medicine above. Um okay, I think that was everything that we want to talk about was just going to take a short pause for any questions or just a breather before we go on to a couple of case studies. Um, that's okay. There might not be any questions yet. That's fine. Um, I'll just have two minutes. Okay. Well, I think there was a bit of a technical hitch there where it might have cut out in the lecture. So apologies about that, um, but if anyone's got any questions or anything can revisit anything back to the end. Thanks again for letting me know. Um, okay, I feel like, Well, give one more minute, and then we will continue. I think it's just about starting to get light in Australia. You will be glad to know, but I've been on nights, so I'm okay. But let me go write everybody, um, Ready. And we will continue This part might be a bit more interactive. I might ask some questions. Feel free to use the chat function or just in your own head. If you've got a piece of paper there, Just think about what you would do. Unfortunately, on this way, I don't think my delivery is in the The timing is coming up. So it might just come up at once with being a pdf. But we'll just try and imagine that we've got a moment to think about what you might do if you're an f y to going to see some of these patients. Okay. Um, so we'll continue right briefly. And I think Ben may have hilariously had a slide very similarly to this last week in his lecture and but before we started about some referrals. I've just gone over some of my tips for making and receiving referrals. So, um, the biggest thing having been on the end of making them currently being an e. D at the moment and also having been on the end of receiving referrals for pizza subs and gave me for, um as an f two, Um, you basically need to make sure you have your information before you get on the phone, and you are well, within your rights as a person receiving the affair or to just say, Can we just go back? And can I just get that in an SVR format? Because everybody will know what you mean, and it just makes it a lot easier, and you can say it in a really nice way. But you basically want to go through the situation, the background, the assessment, the response and then their recommendation. So it's a universal tool that's used for making either a hand over or referral more efficient and safer, and you can get all sorts that you yourself are calling up patient of. I've had it before, where I'm thinking, What am I talking about? the moment. And you can also be on the, uh, the receiving end of the phone and think, What is this person talking about The moment. So if you're making a referral, just take two minutes to write down the information that you want to say in these important salient point, especially if you're not used to doing it. And in the same way, when you're receiving a referral, make sure you've got a pen and paper handy. You've got your list or your, um, notes or whatever you use. And just make sure you've got the information that you need before you accept that referral, because it will save you a lot of time and headache and in the in the future, um, also want patient information where they are the main things. You're three ps patient information. What they really come in with just so you can get your head around it and the plan, or what you need to be doing out of that. It's also really important to just check in with how worried you might be about this patient. So, um, a good question to ask or a good piece of information to give is the level of concern. What's the new school that can immediately pick up somebody's is Or you just say I think this patient is, um Well, this patient looks, um Well, I'm worried about this patient. They're all good things to either. Say to your senior, if you want to escalate and get some help or if you are making a referral or if you hear that on the on the phone, you think this might need to go up my priorities list? It's also important when you're taking a referral. Um, just to make sure that they department have your information, your number if you're handing over or if you're If you're, um you know at the end towards the end of your shift, this information can be important for the receiving team. Just to make sure that they know who to contact, um, if they have any concerns or if they're worried, or if things change if things change. Another good tip to know is, Is there anything for that team who is referring to the patient? To do that you would like them to do before you managed to see the patient. Often you'll be on a very busy on call shift. You have lows patients to see, um, nothing quite like coming to see a patient. And you realize no one realized they need to do any blood or urine dip hasn't been sent or some basic things that wouldn't take any one too long. Just didn't think they need to be done. Whether that's an E c g, whether that's whatever you might need. Just make sure that as part of you accepting to say any chance, if anyone has a moment before I get there, would we be able to get you. Make sure your urine's been sent off. Blood have been done, and X, y and Z. Maybe scans are a tricky one, because I think if you want the scan as a as a team, you should probably be the one requesting it. But if you're really busy, you might want to ask for help and see if the CT team can help you out on that, which I think it's completely fair. Um, if you're getting a referral and you're thinking this patient sick, I need some help. This is my phone and then you might just want to immediately escalate your senior or informing D that can they get A and any GI consultant or Reg to go and see that patient before you get there? Because at the end of the day, no matter how busy everybody is, sick people take priority. So if you're listening to this and thinking I'm going to need help with this, there's no harm. You can get there and hopefully lay eyes and examine the patient first. But you can always flag to your Reg or your consultant. By the way, I'm going to see this person. Uh, by what I've been told. I'm worried about them or if it's, for example, a caution. Um, did you want to come or can I call you? Just say that they're aware it's a nice thing to have to do. I don't know if you can hear the birds. Apologies. There. Very loud. Um, okay, so Referral one, um, it's your first week as a urology f y two. That should be called in to and not an s h o. Because you've never done any urology before. And somebody calls you saying Oh, yes, we've got a 79 year old chap. He's had a collapsed at home, but he's known to the urology team. I think he's got a cat already. Um, and he's got some letters with him Were really busy down here. He's got reduced you about the hematuria. One of the, um, one of the F one has has seen him, But any chance this man is going to need to probably come in by urology. Can you just come and see him? And you're thinking Oh, yeah, yeah, of course. I'll be there as soon as possible. Okay. Um oh, gosh. Hematuria Let me think about what I know. And you're a bit flustered and worried. Um, so you know, you're thinking, right. I'm going to go and see this patient, but let me just think roughly in my head what the differential for hematuria might be. What might be happening with this elderly man that's come in. So, you know, he might have some stones, you know. He's got a catheter in already, so he might have known BPH. He might have a tumor, and it might be an infected picture. Um, like, and then you're starting to think I don't I don't know what it's like. I don't really know much about this chat. And you think Oh, yeah, I definitely didn't get enough information from this hand over. And there's also some other, um, differential that I mentioned, like emergencies and polycystic kidney disease, which is a bit more weird and wonderful, but I just wanted to include them, so I mentioned them. But you're thinking you're going through these differentials in your head and you're thinking I definitely don't have enough information. So never feel afraid, especially just to call back and say my slides, we'll load. Um oh, yeah. So these are things that you could be thinking. Um, And then you're thinking I actually didn't ask what his observations were Did not get into my classic spot hand over from this man or my referral. I don't know if he's had a urine or what his ribs are like. I don't know the urgency in which I need to come and see him. I realize he's had a collapse. Um, do you know if that's a urological cause? Or has any other investigation been done? Is he got an infection? Is this visible hematuria? Have we checked? It is a microscopic versus macroscopic they mentioned the urology history. I don't know any of this information, but these are all the things that you're thinking about. Feeling a bit overwhelmed. Um, so it's definitely fair enough to call them back and just say, I'm so sorry. I know you mentioned that. Can I come and see this chap? Just get busy and I just want to know if I need to prioritize them. So, um, it's completely fair just to call back and say Can I just have a little bit more information just so I can get any other information that I need to before I come and see this patient? So going through our Esper, the situation, it would be a 79 year old male. You want to make sure that you've got three points of idea for this chap, So his name and date of birth and maybe a patient I d. So you can look them up on the system. You also want to know where they are always really important to know and and where you're going to go and see them. You find out in his background that he's recently had a terp a t u R p t. Three days ago. Um, he's not normally catheterized, but it was just put in after this. And then his daughter brought him in because she found him very confused and collapsed at home. And daughter noticed a lot of blood, which really freaked her out and so came into E d. Um, he does have a low grade fever, and he has a little bit tachycardic. He does look like he's in pain on his assessment, and he doesn't He he looks like he could become, um Well, he's not sick at the moment. His other observations, his news is okay, but he's a bit borderline. And he's 79 so yeah, it would be good. Um, basically become review. You've They've done some observations. They've done a urine sample, and they've done some blood, which are pending. Um, but you're thinking, Yeah, I'm now ready. I've got information that I need to go and see this man. Um, for instance, I know where he is and what his name is, which is always very helpful. So I was going to ask you guys what else you would like if you could think about things. Other investigations that you might want before you go and see this guy to ask on the phone, especially if you're really busy. But they've all come up for you now. So things like you can ask for somebody to have a bladder scan, especially if they've got a low urine output. Or if there's a worry that the catheter is not draining, it might be something that you asked to get before you go. Um, if you're worried that this patient could be septic, you can say if we've sent off a urine culture or, you know, taking blood cultures already, please can get them started on some antibiotics. As for the trust guidelines, I think if it's going to take you longer to get there and they say that golden hour, um, normally it turns where you work. E. D may have already initiated the first set of management, but you can always ask somebody to be started on some antibiotics, Um, so that they don't become more and well in terms of him having a collapse. You want to think laterally so it might be worth just getting things like an E C G and making sure that's happened already. So you've got all of the information that you might need before you go and see this man. The other thing is, it's your second day of neurology. You're thinking, Oh, I don't know what it is. And that's absolutely fine, because you may just need to revise what procedure your patients had before you go and see them. So a terp is a trans urethral resection missed out the key word in that of the bladder tumor. So, um, here it's in this top picture, um, early bladder tumor. Um, if it's been, um, someone's presented with hematuria say this is a little bit down the line. They had a cystoscopy, which is, um, a camera going into the bladder. And they noted that the tumor is there. And if it's, um, if they're able to, they might want to try and resect it with by the urethra. Um, and so you might want to just refresh your mind before you go and see this person on what the post complications. Maybe what might be normal after present after being three days after this procedure versus what's worrying and what may be a complication? Um, there's a lot of acronyms as an oral medicine, but especially in urology, I think. And it's not to be confused with a terp, which is done for transurethral resection of the prostate. And that's when you have BPH or sometimes thinking prostate cancer. Maybe as well. You can have that done and sometimes can be quite confusing, especially if you're not necessarily familiar with these. Um, a lot of urology is under urology, where they go through the urethra and have a look and do it there. So it's just, um, they have quite a lot of minimally invasive closed techniques, so it can be important to familiarize yourself with how they use a telescope and what size that is and what damage it might be doing. Um, if you're going to see these patients, just just a little side note. So you managed to get to see this chat and you decide to you've managed to find some notes on the system for what the procedure is for, and also you've got a detailed plan, maybe some more detailed than others, depending on the surgeon, the consultant, um, as to what the follow up plan was and what the expectation for this patient is, um, so that's always useful to have going in and trying to just briefly, depending on how well they are, if you can find that information before you go and see them. Um, this man is there with his daughter so you can get a history from both of them, which is useful. Um, so Okay, um, it was a bit of pain initially, but he'd been discharged with some pain relief after the procedure. The Catholic was causing him a bit of a bother. And he had had some bleeding. And hematuria, which had been told, was normal for him initially. Um, but that has seemed to be slightly settling down and and then over last night and today, he just felt really shaky. And, um well, a bit more confused. He lives at home alone, but his daughters nearby. So he called his daughter and his daughter had a few minutes calls from him in the middle of the night. Um, he then had some pain. Um, and this is a very good history from a confusing nine year old man. But you get the general dressed. Um, he then called his daughter the collateral history from the daughter is that she'd come him. She found him slumped near his chair, which he said he was trying to get onto. She noticed in the bag fresh red blood, which hadn't been like That's bad recently. Um, and that he just wasn't right. Um, I was feeling a bit thirsty, but hadn't had much to drink. So you've also noted that in this patient's history, he was previously on blood thinners, and they were advised to be restarted. Um, you're not quite sure why, but he has restarted his blood thinners, um, that he was on sale for a F recently that he had stopped prior to the procedure, and now he's back on his warfarin or his rivaroxaban. Um, but he has been off these for a little while. Um, so I think it's important, even though you're there with the urology mindset just to keep your net wide and ask some relevant history points in terms of his collapse. Um, important things. Postoperatively. You want to see if he's been more if he's been more mobile? He's had cancer. Um, he's had a collapsed. You might be thinking about pee, and he's been off his blood thinning medications. Um, so you asked about his breathless. Does he have a cough? Does he have any infective symptoms? We've already talked about any fever, any signs of sepsis? And also, how much blood is he losing? They might have done a gas initially, which can give you your first HB, but is he feeling breathless in terms of, um, that could be a sign of him losing blood. Um, so just important things to go through. Obviously, any history will probably go through the presenting complaint history of that. You're checking in with his past medical history. But it's just important to have that rule in or rule out of criteria that you might be worried about. Um, in terms of you might also know the escalation plan for this man. So what? The aim of his bladder cancer treatment was, which can be important when finding out also for if he's got a late stage, um, bladder cancer. Um, this man might not want to be in hospital. Um, unlikely for three days, post procedure. But it's just important to remember when you're in general when you're seeing patients just to make sure you know, um and speak to them about it, what the aim of their treatment was what they want to happen, what they think is going to happen just to manage expectations. And also just to make sure you're on the same page. Um, it can be an important converse to start to have, especially if somebody is becoming unwell. And as part of your history taking, I think we should get better and having um, pre emptive discussions about the plan and treatment plan. Then we'll tell you. And he's very good preventive medicine. But on his previous general surgical starts, I think you might mention, but it's just important to have in the back of your mind, especially with this patient group, right anyway onto our examination. So with everybody, wherever I see them being in D, I do all the time. But also, when you're going to call to see a patient, an award or constipation e d. I think a to be just the easiest way to make sure you don't miss anything. So with a check in the airway and they alert they speaking to you. Um, and if we could, without move on to be check their lungs to have good air entry, any cramps, any crackles, any wheeze. What's their work of breathing? Like, what's the respiratory rate? What are their saturations? Um, if that's all okay. And if you're happy that your breathing is okay, um, obviously, you know this chap, He could have low sats. Um, he might be in pain. It might be breathing quickly. Um, just good things to monitor. And just to make sure that if we need to get him with some oxygen to help that we can do it this time, which probably would have already been started by a mg See, he realizes tachycardic. He's a little bit borderline, but he's going between 100 100 and 10. He's a regular, but he's known to be in a F. He's got quite a high BP, but we know he's been in a fair bit of pain, so he's, um, hemodynamically stable at the moment. But it's just something good to check, especially for patients bleeding a lot. Want to make sure that he's okay and that is not compensating. So just to monitor those as you're going through with C, also looking, Has he got a line in. Is he having fluids? Especially if he's a bit dry. And if he's a bit shocked, what's his urine output like? So let's have a look at the urine bag. We'll see how much is in there. We've got an input output chart going with his clothes in his urine. Is there a lot of fresh blood? Can you see any clots in that urine going on to be checking his GCSF? He's a bit confused. He might meet the, um, with verbal, so he's about 14 out of 50. You can also check his sugar. Um, in this part, I do my abdominal exam. So make sure is his bladder palpable? Is he in retention? Um, is he draining enough urine? You can do a neuro exam just to check his arms and legs. Um, no signs of quarter equina can do a PR at this point. Or you can come back to do this later. Depending. But just make sure that it's part of your abdominal examination and and your your exam as well. Um, anything else? But I think if that's all okay, we're going to eat. Just check everything else. Make sure his temperature is Okay, Check his calves. No sign of DVT. And at this point, you're checking. I always just do a check. Is there anywhere else that you're in a significant amount of pain that I've missed or any other injuries if he's had a fall just to do a top to toe check? And he tells you at this point that he's got significant pain from the tip of his Penis as well, you know that it's a new capita, but at this point, it's always good to check. Um, and you can call in a chaperone. Um, at this point, especially if you're going to do, um, like a closer examination and a prostate exam. A Chiari as well, a PR. But he tells you he's got significant pain from the tip of his Penis. You have a look with a chaperone, and it isn't playing. There's no paraphimosis. Yeah, there is some leakage from this around his capita. Um, but, um, also, sometimes in confusion, patients can talk about have to pull them out. So it's just something that's important to always check just any coma as well. Okay, so you have now more of a picture. It's only four history and your full examination, you go to think about investigations. He's already had his observations done, and they should have been done regularly. He's had some your analysis that sent off and there was just so much blood in his urine. That's pretty much that's all that's going back, maybe a trace of Lupus. But it's not particularly, we know, reliable in an elderly person with a catheter, especially no nitrites, which is what you look for because nitrites will normally show that you've got an infection and somebody has done a bladder scan and he is passing urine. He's not in retention, but it's just a lot of hematuria. And he has done a PCG, which shows this a F but it's very similar to the previous CCGs his blood, you know, go to the computer and you see that they've come back. He's, um, in a mild AKI. Um, and you should always check to see their kidney function, especially prior to getting antibiotics, which will come on two. Um, but you notice that he's got a fairly good going white cells and CRP He has just had a procedure. Um uh, something to note his H B has dropped. So looking at an HB, um, it can sometimes depend on your trust guidelines as well. Often you're the best way to get an H be initially is to do a VBG because that can come back very quickly. And you can work out what? How worried you are about that patient. And if you need to be doing a group and hold and ordering some blood, Um, normally, I'd say anything more than a drop of 10. You're lucky that this man will have had recent blood done because they have been in the theater so you can compare it. And if he is dropping blood and more an alarming rate, Um, it's just something to be aware of. Um, if he's had respiratory symptoms, you might want to check that he's had any other imaging that he needs. Um, I don't necessarily think this man you might think he needs an ultrasound. But if there's any concern of perforation, which is just you're worrying, you're most worrying. Complication from a terp is, um, that will need a CT. Um, you're thinking this doesn't sound like it's been three days since the since the procedure if it's been perforated, probably would know about it already and before he's gone home. You would hope, um, but that's just something to be aware of is your most probably worrying complication from this procedure. But the common complications being blood infection, clot retention, Um, they are the kind of vague differentials at the moment or just, um, losing blood. And he's bleeding from somewhere. So you go to your initial management. I always use buffalo as my septic. Six. That's what I was taught at uni. So your blood and blood cultures checking your urine output and and also just check these and these, um, fluids, antibiotics, lactate oxygen. So I have this in your mind. Anybody with the temperature, anybody that you're worried about an infection. Just make sure all of these things that you're covered for initiating because it will help you time and time again. Um, so for this man, we've got some fluids going. You've checked his kidneys and you've looked up your trust guidelines, and you think I'm going to cover him with some IV antibiotics. He's got a low grade fever, which we know in the elderly. Often, patients don't always get a temperature, Um, but his white cells and his CRP and his general picture enough to say that we could cover him from an infection after this procedure, getting energies are on board. I think it's easy to forget, sometimes bizarrely, when people are more unwell. We forget that they might be in pain as well. Um, but I think that's really important to helping this man, just to see if that can help settle him, that his tachycardia and his high BP on because he's in so much pain and discomfort because of his capita, Um, or that he's a distressed and has been trying to move around. And that's what's causing some of the problems as well. So very good to help patients become more settled. As I mentioned before, we've done a gas check that HB and we've got formed bloods going, and that might help us guide if this patient has, um, just recently started their blood thinning medication and then has bled a lot, and the main thing is, and you can often get to the stage before, If you're worried about them and you're looking at them, you can call your red or your consultant. I think that's completely fair. As soon as you're worried you can escalate, I would have no a very low threshold escalating, especially when you start your job and then also your whoever's done the procedure will want to be informed. And the consultant on normally will, um, want to have a look at a patient, especially if it's a POSTOP. And obviously it depends what you find from your results on your scan. But, um, that will depend on what the senior wants to then do, um, this patient, especially if they've not been producing as much here in or if they were in retention, they might need a cap to check and a wash out. They might be started on some irrigation to help in that blood, especially if there are lots of clots you might want to check at this time if they need another team to see them, especially if you were worried about a P or if they were in fast A F or you're concerned about the blood thinners or just have a very low threshold for also consulting other teams where you're you might not get help from your your gyn search seniors or your urology seniors. They might need to be seen by the medical team as well. If it's an infection, I think normally a patient like this would come under urology because they've got a strong neurological history. But if it was a pyelonephritis that you've seen and you thought it was just a part of arthritis, that might be where you then refer on to another team that may need to accept this patient. Um, so this patient, I think, would probably come in. Um, obviously depends on the numbers and how they're doing. But you'd want it was very common on my urology ward to have patients like this and those with bladder cancers unfortunately often are prone to getting hematuria often if they were on blood thinning medication as well. And it would be a balance between getting their warfarin and their iron are that's something also, to check if they're on warfarin. Um, iron are versus how much they're bleeding. Um, and it can be a very fine balance, and unfortunately, doesn't mean that these patients are often in hospital a fair amount just to make sure that we can, we can get that balance. Right? Um, And also, if they are in pain or if they have an infection, that might need treatment prior. Okay, so it was fairly less interactive than initially planned. But we will. We got at that time already, and everyone's doing okay. I'm sorry. It's actually got a fair bit longer than I was expecting, but well was through. And the urological cancers. And these have just briefly spoken about and the bladder cancer. But just to note that these five are, what, um, the urology team will be looking after, and I've got some more information here about the interest of time I'm going to quiz on because I've been chatting away. Um, okay, so these two are fairly quick, and we've been through them all ready, So I just went through this quickly. But obviously, you need to go. That's fair enough. So, in terms of, um, this you've been referred a female. You've got long to grow in plain. You asked to review her. But you know, now you're going to get more information straight from the off. So you have all of your information. You have that she's got right back. Pain. You know where she is. She's got a previous history of stones. She's slightly tachycardic and has a low bp. Um, so you asked for a urine dip and a CT, and you will come and review her when the CT has been done. And as you mentioned before with renal stones, we know that to accept them on the urology, they need to have a CT. So your initial thoughts, what you're going to go through if she's a child bearing age, always make sure you do a pregnancy test. Check the urine output. And most importantly, with this lady, you want to rule out any red flags. So you want to make sure that her a water is okay and it's not a triple A for this lady. Um, she has right back pain through to her back. It's worse when she takes a big breath in, Um, she is a smoker, and she recently had co vid There is a bit of a cardiology history there. So, um, you just are wary when you're going through that. There might be some red flags in her history that you want to check in her examination. She's okay. We've gone through a TUI. She is, um she does have some pain when she takes a deep breath in, but she is, um she's in quite a significant amount of pain. Um, and so it's quite difficult to assess. Um, but she is tender in her flank side. Her observations and her knees are all okay. I'm flying through a little bit faster. So these are your main differentials. So obviously any we're considering renal colic, But it's important that when you come and see somebody, you have an open mind. And don't try and get bias by what they're saying. Um, so we want to rule out a Triple A or an atypical M I. R a p as other differentials from this history, especially with her having co vid um, having a cardiovascular history, that right flank pain can be referred from cardiology or from the aorta. So it's just important to bear in mind. Um, and we think about the right upper quadrant pain, but we know that can go through to the back. And we also think about things like S K. If you're less worried and if there are effective signs pyelonephritis and renal colic would probably be my top to hear in terms of imaging. Um, so we've gone through our standards Observations, your analysis, BCG and bladder scan. We want to make sure we've done the details of neurological exam in this patient. If she's got back pain, Anybody with back pain, you want to reduce the red flags? So, um And so basically, um, you will check for you sneeze. You want to check for infection? If she's got a concurrent infection, then you might want to make sure that she's on antibiotics as well. And you want to have a feel for that? In case you're worried about that obstructed, um, infected kidney. We can get an ultrasound, which is often done first and a chest X ray. But the CT K U B is the gold standard for accepting to refer to urology just to make sure that she has not got not got a Triple A, but also to look for stones. So we've been through the management before for this patient. We've always ticklish back for analgesia there, Okay? Not allergic to IV fluids. I've catheterized this lady if she's not producing urine. Um, if I'd be debatable if she's infected. Instructor, definitely. But you want to just monitor the output of the other capital. And if she's coming in, these patients do like to get a capita. After you've checked her kidney function, often it's gentamicin. But you just want to make sure that they their creatinine clearance, is okay. And then make sure you document the time and because then that will help the patient. If they're going to the ward. Them getting their gentamicin levels done, which can often be tricky. Getting the timing right. Um, the admission criteria for this patient would be if she had a stone that was more than a centimeter. She was an A K I. She was septic pregnant, had a unilateral kidney or was in pain. If she needed decompression, that would be where you're escalating to your senior. If you're worried. Anybody with a unilateral kidney definitely escalate as soon as possible. And also, um, if you if she needed a nephrostomy, that would be where you would go, um, to straighten your senior. Um, as we mentioned before, you need to follow up your discharge patients. They might need CT scans arranged tamsulosin analgesia safety net that the pain can go on for three weeks, and if they need any other investigations further on, But we've been through that earlier. Um, I am going to skip over this, but I'm just briefly included here, which you can come back to at a later stage with the link. Just the neurological procedures that will be comin. Nephrostomy is your interventional radiology and frosted round, where they put the contrast side through to track. And the ureter extent is what sits inside between the real, the palace and the bladder. Um, so the urine comes out and the stent is inside. It's just important to know when they're talking about these interventions. Okay, And last, but not least, nice and quickly, Um, this is a 20 avoid that presents abdominal vomiting. He got triage, uh, A and E. And it was thought to be maybe a gastroenteritis. He was given someone down to try and pop back out to the waiting room. And you get a very panicked call from, um, an E. D registrar saying we've had this man, he's been in the waiting room, but someone's just examined him. And he's had this left abdominal pain He's been vomiting. They thought it was gastroenteritis that someone just had a look. And he's got a swollen left testicle. He's got a borderline temp. He's in agony. Can you guys come ASAP? Were already a bit behind it. It's already been two hours, and he's been badly categorized. Unfortunately, does happen. So we're now in a bit more of a panic. Were thinking We've got only four hours. I need to examine this. This man, I don't know if we've got time for an ultrasound. Um, so what? I need to speak to my consignor basically and get them on board as soon as has he had a urine dip? Just make sure he's not by mouth, in case he does need to be prepped The theater. Um, so in your panic, you run down and think this is a priority. I need to go and have a look. You do your Socrates go through his pain? Um, he has been feverish and he does have pain passing urine. You find out when you're doing this history. This has been gradual pain going on. So you think Oh, I do. I think this is portion. It's not sudden onset. Um, there are a few other things going on here, so it's really important to always take a sexual history as well when you examine him. The salient things in the salient point in your examination is his this lower abdominal pain that radiates into the left testis on this left side, um, and that he's got a low grade temperature. Um, he's a young, trapped, otherwise fit and, well, he's got no other problems, no significant family history of caution. Um, so then you examine his testes. He has a red, warm left scrotum. It's painful. It's swollen. There are a bit of skin changes you can notice. No cramps that reflux, but you don't really back yourself. Um, the pain does get a bit better when lifting the left chest. He's that he's not sure because it is just really painful, and he's feeling pretty sick. You shine light through there is no worms or any of the other things that you've been talking about. So you quickly just having done your examination, go and chat to your senior. So again, just differentials. Torsion is the thing that you always want to rule out a painful testicle you know is to wash in until you can rule it out. But other things. Um, you're thinking maybe this is a sexually transmitted infection or epidemic itis. There are some signs of UTI. There he was Pegasys and gastroenteritis previously. Wrong side for the appendix, but people can present in different ways. Um, And then we've got some of our on examination painful riding around one side. You're thinking renal colic as well. Could be an option, but less likely in this presentation. And so, um, the senior actually comes and he has a look as well with you. Um, another technical error. Not helping me being speedy to get you all the way and bear with me. Um, I know we've gone over guys. Sorry about that. Me being tired at four o'clock in the morning, but then might post some feedback in case you have to go sooner rather than later. But basically, you come with your senior, and, um, they do a urine dip, which does show signs of infection as well. He has a right raised white cell count and CRP, and they decided to get an ultrasound for this because it is a bit borderline, and we found out we have time. It's daylight hours, and so that does show some signs of any enlargement. And therefore we do some swabs as well for chlamydia and gonorrhea and manage this as an epididymal colitis. And so we have proof an ultrasound that it's not a toy or shin. But you've done all the right things because you know that the testicle is talking until proven otherwise. So this chat. Get some. I am chemistry accent, and he gets sent home with some doxycycline. We chase the swabs for contact tracing, and you took him a follow up ultrasound just to check the testicular cancer. To be careful so well done. I think that is the end. I've just got some final thoughts that I want to chat through really quickly. Basically, we haven't really talked about your a game here, Um, but I always because I it's my favorite thing. So just to be aware that if somebody has a PV bleed, it can sometimes be mistaken for hematuria. So it's often a good idea to do a speculum. If you're not sure where the blood is coming from in these patients, it happens quite a lot that they get marked as having Frank hematuria and often it can be a PV bleed. So that's just something to be careful of. Um, uh, guidance counselors as well always monitor urine output and fluid input. We have a lot of problems with heart failure patients getting the right balance between dehydration and overload. But catheterizing doing a strict input output will always be the right best way of trying to manage that Here, if in doubt, manage the sepsis. Um, because again, that's something that if you give antibiotics no one, they can always stop them. Um, it's better just to be careful. Um, I have a surgical ward round acronym, which is subjective, subjective assessment and plan, which can help you if you're going really quickly and a surgical sieve, which is pain infection, nutrition, constipation, hydration, medications and everything else. Classic. Just to make sure that you are trying to, um, cover everything or electrolytes as well as you're going through just to make sure that you don't miss. And that's useful not just for surgery, but for anything. When you're reviewing a patient just to help have a framework, always safety net When you're letting people go home, tell them what to come back with. Give them information and you can give procedure leaflets you can print off. The British Society of Urology has loads of really good ones, and I think we are finally at the end. Um, apologies for running over away with the ferries this morning. I just wanted to say that we have done a previous urology lecture, which is amazing by one of the urology. Reg is who is probably not a consultant from a couple of years back. If you go on to our website, go through the curriculum, all of our lectures are on here, and there's amazing content. In 20 20 we did a series of specialty webinars, and there is a specific urology detailed lecture there which goes through some really useful capital help. I've briefly touched on it today, but I would recommend going there, and I think that is everything. Head on our website. We've got all our lectures there. Um, Ben's will post hopefully his, um, slides from last week to go back and have a look at the General Surgery one. And then next week we have to you know which is very exciting. And I hope you guys have enjoyed it. Feel free to ask any questions. Um, I hope it's been useful, and you can always watch back if we rushed over any of the parts. So if you've got anything else, just let us know, okay?