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OK. May, yeah, I'm just trying to figure it out, I think. Can people hear us now? Ok. Ok. I think. No, no, sorry about that. No technical glitch. Ok. So this is kind of just the, the basic run of the session. So we're gonna go over the SBAR framework first and just kind of maybe some er, potential SBAR scenarios that could come up for your er M and M OSK then gonna go over a basic ent history taking, incorporating what you already know and just tailoring it towards ent scenarios. I'm then gonna go over some common ent presentations such as like dizziness, uh hearing loss, sore throat and neck lumps. And then if we've got time at the end, I'll, I'll quickly run over ENT examination just because it, it came up in my oy last year and it, it, it tripped me up a little bit. So if we've got time, I'll, I'll happily go over that at the end. Ok. So SBAR just stands for essentially what you're gonna be doing. So it's situation, background assessment and response. So in situation you wanna introduce yourself, introduce the patient and kind of the main problem that you think you're facing and background, you want to include all the relevant clinical information. So you're gonna be given kind of a scenario in your OSK and you'll be given, um, some information on the patient, er, potentially some investigations or bloods and you have to interpret it and essentially decide for what you think's going on. Pick out the relevant information and put that into an SBAR scenario. So, in the OSK station, if you're in Manchester, you'll be, you'll have a few minutes to read through the information and you'll have a piece of paper and a pen. So, what I'd suggest doing is writing SBA R down on the paper and then when you're reading through the information, jotting down bits of the scenario that fit into each category. So into the situation, jot down patient's name, patient's date of birth, hospital number, what he thinks going on, er, and then in background, they're relevant, clinical information, relevant medications assessment will be kind of your observ, your obs, your examination, findings, investigation, findings and then for response, it's going to be, uh, you're gonna, you're probably gonna want a senior to come and review them. So you're gonna need to state that and then what you think you should do and then you can ask, you know, if there's anything else, um, that you need to be doing in the meantime. So I've, I've just got a bit of an example, er, coming up next. So this is a 67 year old woman who's had a left total knee replacement. Um, so the surgery is without complication, immobilizing. Well, but she's now developed pleuritic chest pain, sudden shortness of breath. She's on 4 L of oxygen by nasal cannula, but she's still hypoxic. I've got her past medical history there, hypertension hiatus, hernia, high cholesterol C KD IBS, osteoarthritis, er, meds just for all those conditions above and then on examination. So she's anxious, increased, worth of breathing, apyretic, tachycardic, um, hemodynamically stable, um, increased respirate and then decreased breath sounds on the left. So based on this presentation, um, it looks like the patient has probably had a pe or if we were presenting this in an sbar, you know, we'd be thinking towards pe. So then if we're thinking how we're gonna structure this, um, I've got how I, how I present it on the next slide. But yeah, we're just picking up bits from this. So we'd say that, you know, we've got, er, Jane Doe, 67 year old female, blah, blah, blah, er, date of birth hospital number who's now got sudden onset shortness of breath, er, with pleuritic chest pain, I think she's having a pe um, and then if we're picking out parts of the medical history, which are important. So, hypertension would be important as a risk factor. C KD would be important because it'd probably make her, um, not want to have a C TPA and instead go for a VQ scan or something of that um medication. So she's on Delta Pin. But, you know, people can still get um P ES when they're on blood thinners and then exa examination findings. So she's got increased work of breathing tachycardic, but she's hemody stable um, and decreased breath sounds on the left. So just putting that into kind of the sbar form, this is kind of how I'd run through it. I mean, obviously you wouldn't be able to write all this down in, um, an osk if you haven't got the time, but if you just practice it a few times, so you wanna introduce yourself first. So how my name, I'm the F one on call, make sure you confirm who you're talking to as well. Er, because, you know, sometimes people just pick up the phone and it could be just a switchboard. You need to make sure that you're talking to who you want to be talking to. So it's probably either gonna be like the, the on call, er, medical reg or the on call, surgical reg or an anesthetist. So you say who you've got date of birth, hospital number, confirming patient identity and then what you're calling about. So she's got a sudden onset shortness of breath and pleuric chest pain over the last hour. I'm concerned she's having a pe, so that's kind of, you let them know straight away what your worry is. So, then they know kind of what information to listen out for so they can kind of make a judgment on it. Um So that's sort of background of her going under this total knee replacement. Um And then you also, you in, you include the, the relevant past medical history. So the hypertension, the C KD previous smoker cos they're kind of risk factors and they'll dictate how your management goes moving forward. Um And then you can move on to assessment. So, you know, she's tachycardic, hypoxic. And if she's hypoxic, you make sure to let them know what form of oxygen she's currently on and then she's got um high respirate, increased work of breathing and decreased breath sounds. So that's all kind of still pointing towards your pe and then recommendations. So you say that, you know, I believe Jane needs an urgent BQ scan rather than C TPA, please. Could you come and review this patient urgently? And is there anything else you'd like me to do in the meantime? So, you know, if you say, is there anything else that you'd like me to do? In the meantime, you know, you, you're being proactive there. Um You're asking if there's anything else you've already said what you think might happen. But even if you've got no idea, even if you haven't got a clue about, you know, what the, the presentation is or what might be going on, if you include kind of the worrying bit. So you know, if someone's hypotensive include that tachycardic include that if they're pyretic include that. And then for recommendation, you can just say, look, I think I'm really worried about her for these reasons. You know, if you can calculate a new score, fine, do that. But you say I'm really worried for these reasons. I think she needs an urgent review. Can you please come and see her, the sbar stations all about kind of how you communicate and how you get? I suppose how you, you look at the clinical picture and you realize that something's going on and it needs to be escalated. So if you can communicate that to someone else, um that's, that's how you're gonna pass the station. Really. Um And then these are kind of some possible. I ca I came up with some possible M and MS scenarios. So in psych, er, it could be, you know, someone who's, if you recognize that they're sepsis with neutropenia and they're on cloZAPine. So that's, that's always a red flag if they're having a manic episode, you know, maybe that they've, they've already had an episode of depression and now they're having this really manic episode um that you need to recognize, I mean, that one's probably less likely because they maybe test your knowledge about the mental health Act on an ethics station instead. But it, it's just something that, that could come up neurology. Those three, I mean, could definitely come up to stroke you, you're pretty, I'm sure you guys are pretty well adapt at recognizing signs of stroke. Now, you know, visual changes, speech changes, weakness and kind of the patterns of stroke, um called a Quina. So it's that saddle anesthesia and that bilateral, um, bilateral sciatica or bilateral er, leg pain and then s as epilepticus. So, you know, if there's a seizure that's been going on for five minutes and it hasn't resolved, um Then you're gonna need to escalate that further to a senior as well. Ent um it, it could come up. Um So mastoiditis, if they've got kind of pain behind the mastoid, er anaphylaxis definitely could come up and then Quinsy maybe so they could give you a picture and show you, you know, a a really enlarged unilateral tonsil and maybe they're, you know, really hypoxic, struggling to breathe, starting to draw. Er, so that would need, you know, surgical incision and drainage. So that might be something that you need to relay. Uh My sbar scenario was ophthalmology. So it was acute angle closure, glaucoma. So it, they gave us a load of information and they also gave us a picture of the eye as well and kind of based on the, the picture and the presentation we had to kind of decipher that it was acute angle closure, glaucoma um relay that on and then say, look she needs seen urgently and I think she was in GP and she came in with her husband and one of the questions I got asked after was, you know, how, how would you like her to be brought into hospital? And I said, oh, you know, her husband's here so her husband can drive her in. But I think they were potentially looking to blue light her in. So it's just kind of, you may get the odd question after, but that's, that's not gonna be kind of pass or fail. That's just thinking about, you know, how, how urgent is this scenario that you're currently in M SK, you know, septic arthritis can definitely come up single hot, swollen joint. Um and that's always septic arthritis until proven otherwise. So, you know, you, you can initiate your um trusts local hot joint policy, go from there, thoracic back pain. You know, if you've got a young patient with thoracic back pain, that's a red flag, they may also have some weight loss and lethargy, er and then fractured neck and femur as well. That could be kind of Jerry's or M SK and it's just thinking about is it, they may give you a picture of a, a fractured neck of femur and if it's, you know, intracapsular, you're thinking there's a risk of avascular necrosis. Oh, so something needs to be done. So, ent history taking and common presentations, I'm gonna go over the er history taking portion first. It's mostly stuff they already know, but it's just you know, what extra details or what, what extra questions to ask during an ent and how to tail it, to kind of ent presentations, I suppose, start off, you know, um, presenting complaint. What do you wanna know? So it's mostly your things, you, you pick out your bits from your Socrates. So, you know, where, if it's pain, the side onset, how has it been progressing, has it been getting better worse, any relieving factors and then any specific ear, nose or throat symptoms, er, which I'll go over on the next slide. Er, so you wanna check for red flags as well. So, you know, bee symptoms, especially if they're coming in with a neck lump. You know, have they had any night sweats, unexpected weight loss, fatigue? Um, you know, Manchester Love ice. So never forget your ice, get it in early. I always like to get it in early once they've come in with a presenting complaint and I've asked about as many questions I can think of around the presenting complaint before I go on to past medical history. I just ask them, you know, what? So what do you think this is at the moment? What do you think is causing this? And what is it that's concerning you to bring you in today? And is there anything you'd like me to do? Just you reel off, you know, three quick questions. You've ticked your ice box and it also keeps the consultation quite patient centered cos straight away once you've come in and ask them about what's going on, you ask them concerns and then you can dig a little bit deeper. So past medical history, thinking about any previous ent conditions. Um, you know, have they had their tonsils out already? Um, have they got any hay fever asthma? Have they got, have they got like an allergic picture going on and then meds, you know, are they on any antihistamines? Have they got any allergies, recent antibiotic use? Uh, when it comes to family history? Thinking, are there any family conditions, er, related to ent? So, you know, if they've got maybe like a bilateral, er, hearing loss at a younger age, you're thinking kind of about Autocross or, you know, there are just some things which run in the family which could point you more down one route than another, er, social just thinking about smoking, occupational exposures as well. You know, all these symptoms that only kind of occur at work, you know, they're only getting wheezy or sneezy at work. Is it relate to their job? And then just a, a review of systems at the end? Uh, so you can't go wrong with, are you asking about cardio arrest symptoms? You know, any shortness of breath, chest pain, cough, um, any neuro symptoms as well, changes in sensation, strength. So, on my next slide, I've just got the kind of, er, more centered ent questions to be asking about. So if someone comes in with a presentation that's related to the ear, no matter what it was, you, you also want to ask about all these things to do with the ear as well, cos knowing about all of these gives you kind of the the best chance of deciphering what, what's actually going on. So you wanna know if there's been any hearing loss, any tinnitus or any ringing in the ears? I told you it was pain arter, any discharge, any vertigo dizziness and then itching and fullness. Um And you wanna be double checking as well. Are these unilateral or bilateral symptoms? So, you know, if they come in and say I've got pain in my left ear, uh also be checking about the right ear as well. Um when it comes to nose. So you wanna be knowing about congestion and sinus pain again, any discharge, any change in smell, sneezing, itching, any epistaxis. Um And if there is, you wanna know if they've been potentially swallowing any of the blood as well, cos that can cause discomfort or complications. So, um that needs to be managed and then polyps as well. Um, polyps are likely to come up. It would be a bit of a weird history, but it's just knowing that like unilateral polyps is a red flag and that I'd need referral. But um yeah, potentially unlikely to come up as a, a history taking station anyway, throat, throat could be, um, definitely one that could come up either kind of on this side of the ear or in pediatrics. So, it's, it's just good to know about. So, you again, you wanna be known about pain, any pain swallowing and then if they've got any pain swallowing, is this getting better, is it getting worse? You know, was it just fluids and now it's food or how is that changing? Uh, have they got any cough? And if they have, is it productive, any change in voice and any neck lumps as well? So, going on to a few common presentations now, uh starting with dizziness and vertigo. So we've got, uh I suppose when it comes to dizziness and vertigo, you've got your peripheral causes, which is essentially your ent and then you've got your central causes as well, which is more like neuro. So when it comes to your, your central causes, it's more to do with, you know, your strokes, your MS space occupying lesions. Um and these tend to cause kind of like real severe dizziness and vertigo where people either, you know, collapse or can't walk at all because they're just, they're completely ataxic due to kind of loss of cerebellar function. Um And these tend to be really, really serious, not that the peripheral ones aren't, but um with the peripheral causes of vertigo, you know, people still tend to be able to walk and carry out tasks. They just kind of feel a little bit unsteady on their feet. Er, but they, they, they both kind of, they come in different severities as well. Um, but your peripheral ones, what I suppose will be covered in ent. Um, so this is all to do with your kind of inner ear vestibular system with conditions such as like BPB V, Menes, vestibular neuritis and viral labyrinthitis, which I'm gonna cover in a bit more detail, er, on the next slide. So these are kind of four causes of dizziness or vertigo, which could definitely come up as a history taking station. So it's important that you're, I suppose able to differentiate between these. So I always kind of think I always really got confused between vestibular neuritis, viral labyrinthitis and I still do at the moment. Um So it's just kind of being able to differentiate between the two when it comes to your history taking. If you put, you know, if you put a couple of them in your differentials, you're probably gonna pass the station anyway. But if you're looking for those excellent, being able to differentiate and knowing how to, that's how you're gonna get your excellence. Um But I'm gonna start with BPPV first. So this is caused by er calcium crystals or otoliths um which move which or I suppose get displaced on head movement. So what's kind of the key defining characteristic of BPPV is vertigo and nausea, which is exacerbated by head movement. So, you might have, um, a patient who's coming to the GP and she says, oh, I get really, really, really dizzy. And is there anything that makes it better or worse? She says, oh, it's, it's weird. It goes away after a few seconds. But it's when I'm rolling around in bed or, you know, when I, when I'm looking around and then suddenly I get these su really sudden onset and it lasts between seconds and a minute and it's only vertigo. So there's, there's no hearing loss, it's purely the vertigo symptoms. You may get a little bit of nausea. Um but BPPV is almost purely vertigo and then you investigate it with the dix Hallpike maneuver. So I've got um a picture of that on the next slide and then you manage it with something called the Epley maneuver. So it's just a different way of moving the head. And what it tries to do is it tries to get the kind of oli crystals back where they should be. So it stops causing the dizziness and vertigo. They have different kind of success rates on different people. Some people find it really helps. Um and they can go, you know, months without another episode or other people, it just doesn't really work. But I always remembered it as dicks to diagnose and to alleviate I know alleviate doesn't begin with an E but that's just how I kind of cos I always get kind of dick and er, confused when it comes to er, investigation and management. But if it's dick who diagnosed eli to alleviate er, many aires is another cause of vertigo, which is more, I suppose, shorter lasting. And this is caused by a, a build up of endolymph in the semi circular canals. It tends to be unilateral but it can be bilateral. So I suppose even if people come in with unilateral or bilateral symptoms, it's good to explore this. Er, and many eyes disease is often associated with hearing loss and tinnitus. So if someone comes in and says, you know, I've got vertigo that's lasting, you know, a couple of minutes at a time, um, it can be, er, brought on by a bit of head movement. So, you know, if you want to dis er, distinguish you say, oh, any other symptoms. Yeah. You know, I've got a bit of hearing loss and I've got this ringing in my ears as well. So that would be pointing you more down menieres disease. It's essentially diagnosed based on clinical picture and ruling out other causes. So, if they come in with, I suppose symptoms which are indicative of men air, you can do kind of an audiogram to check hearing loss and imaging, to rule out other pathologies such as an acoustic neuroma. And then in terms of management, there's, there's unfortunately not too much, um, that can be done for many years. There's no kind of set cure but can you can use betahistine, um, to, I think, relieve some, or sometimes that can work for tinnitus. Sometimes it can relieve a bit of the, the vertigo but it's, it's unfortunately not particularly well treated. Um, and they're just, I suppose a, a slight differential to many hours would be an acoustic neuroma, which is a benign tumor of a Schwann cell, er, wrapped around the, er, vestibular cochlear nerve and that causes unilateral tinnitus and hearing loss. Um, and that's, you look at that, you know what I mean? You investigate that, sorry, with er, an acoustic MRI. So Menes and acoustic neuroma can present quite similarly and if someone came in with unilateral symptoms, those would probably be your top two differentials if it's lasting, you know, around 15 minutes, 20 minutes at a time and to, to diagnose um men air, you need two episodes of vertigo lasting around 20 minutes and then along with the other symptoms such as, you know, hearing loss, tinnitus and then when it comes to basilia neuritis and viral labyrinthitis, um viral, er vestibular, sorry, vestibular neuritis affects the vestibular nerve only. Um So this is only gonna affect your balance, it's only gonna cause uh dizziness and vertigo. It's not gonna affect your hearing. They're both caused by very similar things. So, it's usually they've had a recent upper respiratory tract infection or they've had a recent illness and then this illness has affected either the vestibular or vestibular and cochlear nerve and then it's leading to either nausea or nausea and hearing loss, you investigate them both in a very similar way. So it's again, clinical diagnosis, you rule out other causes. Um, and they're both managing more or less the exact same way as well. So it's kind of this just vestibular rehab. And then if it's got a, or if you think it's got a bacterial cause you can try antibiotics. Um, obviously just being aware that some antibiotics as well are autotoxic. So you probably want to avoid those ones. So, if someone came in and they've had a recent illness and they're now dizzy, er, bit nauseous, find out if they've got hearing loss. If they've got hearing loss, it's to do with labyrinthitis, cos the whole labyrinths affected vestibular and cochlear nerve. Well, if it's just nausea and vomiting, then it's vestibular neuritis. This is the dix Hall Park maneuver that I was just talking about um to diagnose BPPV and the test is positive when this movement here causes vertigo and nystagmus. Um The direction of nystagmus depends on kind of the bit of the canal affected. So you've got kind of like your three semicircular canals. So with these conditions, I suppose the, the, the sags that they cause or will depend on, you know, which, which canals affected. Um But the vertigo nystagmus typically kind of, they get, they worsen initially, but then after about a minute, they should subside and the patient feels back to normal. Um, but yeah, if you a positive dix Hallpike is vertigo and nystagmus, this is the appley maneuver. Um, I mean, I don't think, really think you need, you're not gonna have to do it in your ay. Um, if you're interested, this is just essentially what it looks like and this is supposed to get the oli crystals back into the areas that supposed to be to alleviate some of the symptoms. Ok. So moving on to hearing loss now. So, er, again, very easy, er, I suppose, easy to do history station. Um I suppose you've gotta, you gotta break it down into conductive and sensorineural hearing loss. Er, so your conductive is to do with the outer er, and middle ear and then your sensory neural to do with your, your cochlear er, and the nerves in the inner ear. So, anything to do with the artery can cause conductive hearing loss, you know, if you've got um a blockage in the external auditory canal, er, if there's a build up of wax, if you've got a perforated tympanic membrane, if there's issues with the Eustachian tube, um those are all gonna cause your conductive type hearing loss. Um, whereas an issue with the er, inner ear is gonna cause your sensorineural hearing loss. So you've just got a conductive, it's an issue with sound traveling to the inner ear and then sensory neural is an issue of I suppose processing that sound once it gets to the inner ear and then your conductive is your earwax foreign body perforation, Otitis Media cos there's, if there's effusion, er, the pus, I suppose that's generated can interrupt um, sound waves get into the inner ear. I call the steatoma, I mean, pretty uncommon but it's, it's possible and then autocross as well. So kind of issues with the, the bones of the middle ear and conductive, you know, is often more reversible than sensory neural, er sensory neural. There are congenital causes, you know, of deafness or sensory neural um pre abu or however, the hell you say that, you know, it's just age related hearing loss, not a lot you can do for that noise exposure. So if you've got either occupational exposure or general, just long term exposure to loud noises, this tends to cause irreversible hearing loss, certain medications. So, you know, gentamicin er that acoustic neuroma causes a sensory neural type, hearing loss and then, you know, a traumatic head injury or potentially er space occupying lesions. So when we're differentia differentiating between, I suppose, conductive and sensorineural, um you can use Webers and R so this, I mean, it could come up in your osk, it probably won't, but it's useful to know um for other exams as well. So you wanna do your Webers first, which is, you know, the tuning fork on the top of the head and we expect that to well, we wouldn't expect it to lateralize, we'd expect to hear it equally in both ears. Er, however, if the, if it lateralizes to the left, er, that means one of two things. So either the bone, the bone conduction is better than air. Uh So that would be a conductive hearing loss. So you hear it better on your left or the cochlear component in your right ear isn't working, so you can't process sound in the right ear. So it's a sensory neural of the right. I hope that makes sense. It is a bit of a, a tricky one to explain. And then if your Weber's test lateralizes, then you wanna do a Rin's test. So the Rin's test is where you, you ring the tuning fork and you place it on the mastoid process behind the ear that it lateralized to. And then once they stop here, the ringing, when it's placed on the mastoid process, you wanna move the tuning fork in front of the ear er, to see if they can hear it. So if you move the tuning fork in front of the ear and they can't hear it. Uh that tells you that there is a conductive hearing loss because the bone conduction is better than ear. Whereas if they can hear it fine in that ear, then it's um a sensory neural of the other ear, er moving on to I suppose, throat. Now, sore throat, really common, really common osk er, station, er, it could come off either in ent or peds. So again, it's just a good one to know. I suppose the more common ones that you'd get in an osk scenario are pharyngitis tonsillitis, epiglottitis and Quinsy. With, I suppose pharyngitis and tonsillitis could come up in GP as well. Really, really common presentations and then your epiglottitis and Quincy are more of your, er, emergency, er, potentially an sbar station. So it's good to, I suppose, recognize and differentiate, er, how you'd recognize these. So pharyngitis kind of, as it says, inflammation of the pharynx, er, very similar to tonsillitis, both got very similar causes so often viral causes adenovirus, influenza, you know, general common flus and then tonsillitis. Um, the other big one that you need to know about is uh group a strep infection. So the bacterial cause they tend to have, er, quite similar symptoms as well. So it's that sore scratchy throat, if it's pharyngitis, you're more likely to have, er, adeno. So, you know, painful swallow, you may have, you know, a dry cough, quite fatigued body aches. And then in tonsillitis, it's more like those swollen tonsils, um, submental submandibular tonsils, potentially exudate on the tonsils as well if it's a bacterial infection, but it is quite hard to differentiate between the two, and they're both managed in, you know, the same way as well. So it's, that's supportive if you think it's, if you think it's viral and then, er, phenoxymethylpenicillin, if you think it's bacterial, er, they've just got slightly different complications as well. So, pharyngitis, if it's viral, er, complication would be potentially, er, rheumatic fever. Or if, if that's, if it's, er, a group, a strep infection, um, and it can cause that, er, post strep glomer, nephritis and then tonsillitis, the, the complication that you need to be aware of is, um, it progressed into a Quinsy. So there may be a scenario where someone's come in and they've, they've had tonsillitis that hasn't resolved and now one side's much, much worse. So then you'd be looking towards a Quinsy, um, epiglottitis. Pretty rare nowadays due to vaccination schedule. But the, I suppose it's got quite a classic presentation of usually in Children. They've usually got a stridor, they've usually got drooling and they'll be described as a tripod position or hands on knees trying to breathe. Um, so, yeah, like I said, good, er, rare. Now, due to vaccination schedule management, luckily for you, it's, it's not one that you guys have to kind of contend with, it's just escalate immediately. So that would be the pediatrics, er, or anesthetist to, to manage the airway. Er, and that's a medical emergency, Quinsy. So it's that unilateral, extremely, extremely painful, um, extremely painful throat usually comes on after a bout of, you know, a bacterial, er, tonsillitis. Er, and then this management wise it's gonna be, er, referred to ent for an incision and drainage, er, that again is more common in Children than adults. So this is just, I suppose a little visualization of the four conditions that I was talking about there. So, in pharyngitis you wouldn't expect to see enlargement or erythema of the tonsils, it'd be more isolated to the back of the throat. Er, so there's, if there's FN out, there's probably not a lot to see on inspection apart from potentially just some generalized erythema but not too much kind of swelling going on. Bacterial. You'd expect the tonsils to be uh the back to be really red, swollen, angry looking. Um And then if it's a bacterial infection, you'd expect to see that white exudate on the back of the tonsils as well. Er, the picture here says, you know, looking at the tongue, but I don't think that's gonna differentiate between your bacterial and viral and, you know, a lot of people just have general poor oral hygiene anyway. So I wouldn't use that as a distinguishing factor. I'd be looking, you know, I be looking for the exudate really. And then also we'll go on to the, the fever pain and sent criteria in a second, which is kind of your key to distinguishing between bacterial and viral. Quincy's gonna be this unilateral super angry, looking, really painful, um swelling at the back of the throat. Um, and then epiglottitis, you're obviously not gonna see anything on uh inspection just looking in someone's mouth, but if you, you did visualize the airway, that's, that's what would be going on. So, yeah, fever, pain, central criteria really useful to know. Um cos another oy scenario that could come up would be, you know, the parent who comes in child's got a sore throat. Uh and she wants antibiotics and, you know, you've got to determine based on the child's presentation, whether you think that's appropriate and then I suppose how to communicate this decision to the parent. So, are you sent or purely because I find it easier to remember? So, c is your cervical lymphadenopathy? E is your exudate on your tonsils? N is no cough and T is temperature. Um And then if it's, I suppose if it's two you can consider, if it's three or above, you're gonna give antibiotics, uh fever pain, you know, it's, it's very, very similar but it's just got an extra, extra scoring point. But I'd, I'd w I'd work out or a way to remember one of these for your exams because it's helpful. Um It'll be helpful in both, you know, your CCA S and your progress cos you're gonna need to work it out at some point. So I just like placenta just cos I find it easier to remember. Um Oh, technical errors occur. Oh, no. Uh oh, cancel. Um OK. So, oh, sorry, I don't know what's happened to present now. No, I don't wanna leave the stage. Sorry guys. Bear with me. Hi there. Sorry about that. Can you guys see me? I might just share uh entire screen. I just get back to it. Bear with me. Uh consume, sorry consumer. Just let me know if you can see this and then I'll just, I'll just carry on like this. I don't know what happened to the presentation then. Yeah. Ok. So I'll just, I'll just follow through like this. Um Sorry about the technical difficulties there, there's not too much left but um just a couple of useful kind of scenarios to know. So a common CCA station is a parent's gonna bring their child in. It's probably gonna have a bond or viral um tonsillitis or, or respiratory tract infection. So they're gonna have no extra date. They're not gonna have a fever, it might have been going on for, you know, four days. So a bit of a late presentation, no extra date, they're gonna have a really low central score of fever pain, but they're gonna be set on wanting antibiotics. So it can be a bit of a difficult conversation to have sometimes. Um But you, I suppose need to know kind of a structure to how to handle it. So you're gonna take your history as normal. Um So you're gonna ask, you know what's brought you in today, make sure you're able to work out that central criteria. So go through that asking the questions, work out the kind of score in your head. And then, you know, you're gonna wanna know the parents' concerns. So they're gonna say, oh, you know, I know someone who's had, uh, a group strep throat infection and, you know, they went on to develop something nasty or what are your expectations are on antibiotics? They're gonna be pretty direct with you. But if they've got a low center score, er, you are not supposed to give them antibiotics, especially if it's like zero or one that will be a pass fail for the station. So if you give them antibiotics and cave, you know, that's, that's not a station that's gone well in the end. But what you wanna do is you want to, I suppose, explain the findings to the parent. So you say that, you know, based on your child's presentation, um, or based on their symptoms of this, this and this, uh we use a scoring criteria which lets us know that this is much more likely to be a viral, er, throat infection rather than bacterial. And then you go on to say so because it's viral, antibiotics are unlikely to help in this scenario, then they say, oh, why can't you just give me, you know, antibiotics anyway, it's not gonna do any harm, is it? And then you can say, well, you know, er, for a number of reasons, you know, antibiotics can cause, er, you know, these kind of tummy upsets, er, tummy pain, diarrhea, vomiting. Um, so it's important not to give them unnecessarily. And then you also don't want to encourage resistance as well. Cos it's kind of part of your antimicrobial stewardship. And, you know, people can't just kind of like demand medication. So you've got to be quite firm with them and say, because it's a likely viral course, antibiotics aren't gonna help and could do more harm than good. And for that reason, you know, it's not in the child's best interest to have antibiotics. Um, and then after that, I suppose you can go on to say, or I suppose safety net because, you know, the parents already told you their concerns. So what you can say is, um, you know, after a couple of days, if they're not getting better, you know, come back and see us and I'm happy to kind of review the child again just to make sure nothing's happening. So then in their heads, they're thinking, ok, well, you know, they've got kind of in the back of their head. If things are getting worse, they do have the option to come back and see you. And it's usually quite appreciated. And he says, well, you know, you come back and see me personally cos, you know, it's not a real scenario. But, um, yeah, just giving them that personal touch of, you know, we're not gonna give you antibiotics, we're not gonna give you the for these reasons. However, what we, you know, encourage is rest fluid intake make sure they're still eating if possible, a bit of paracetamol and if things haven't improved in two or three days, which they probably will come back and see us and we'll happily review them again. Um, and see if anything else further needs to be done. Er, final kind of presentation. Um, that could come up in your Aussies is neck lumps. I suppose. It came up for me more in third year than fourth year. I think I had a ab cell lymphoma. Someone came in with neck lumps and I suppose the key for your neck lumps is like your history. So you wanna know about the, the history of presenting complaints. So how long has it been going on for? How big are they, whereabouts are they? And you know, have there been any changes and then uh do not miss if someone comes in with a neck lump, do not miss your b symptoms. So, you know, your weight, your weight loss, your night sweats and your fatigue cos these are gonna be really, really key in, I suppose, differentiating between something that needs kind of immediate attention and immediate referral or something that you may be able to kind of wait and see about. So I think my patient came in with neck lumps and then they had night sweats, they lost weight over a period of about six weeks and the neck lump had been there for quite a while as well. So, it was like, I think a good six weeks it had been there and, you know, night sweats and fatigue for about the same amount of time. So, if someone's had a neck lump for around six weeks, that's a much more. And they've had these bee symptoms as well. That's much more concerning than someone that comes in and says, oh, I've got these kind of p, shaped lumps in my neck. Oh, yeah, I've been ill last week. So if someone's had a recent illness and they've got, er, kind of multiple neck lumps that feel a little bit like peas, um, and they're in the vicinity of where you'd expect lymph nodes to find, it's probably, you know, reactive lymphadenopathy from a recent illness if it's in the center of the neck, uh, around where you'd expect the thyroid to be. And they've been having symptoms of, you know, either weight loss, weight gain, you know, those general thyroid symptoms, it could potentially be a thyroid cause. So then you, you know, you could offer an NT examination afterwards. Um, lipomas, you know, tend to be quite, they can be pretty much anywhere but they tend to be a little bit, you know, mobile under the skin. Er, they don't really grow or change shape. It's just kind of, you know, almost like a little ball of fat under the skin, but they're pretty harmless thyroglossal cysts. So you, you wanna know if it's changing with kind of tongue movement. Um An abscess would be kind of incredibly painful, probably some redness over overlying the skin as well and it'd be potentially warm to touch. Um And then, you know, is it, is it a a mole that's changing um over time? But yeah, neck lumps. It is all gonna come with your history. You just wanna be able to differentiate whether it's something sinister that requires further investigation or, you know, is it a more benign cause I suppose also important to know is again, going back to that kind of family history, any family history of head and neck cancers or any previous malignancies themselves. Er, all these, I suppose things have been more worrying, er, risk factors for further malignancy. And then I, I've, I've still got a little bit of time so I may as well go over the, the examination just because it came up for me in my fourth year. Ay, and it really, really threw me, um, just cos I was expecting just normal examinations and then it was a scenario where, er, it was an exam, an anti examination, half on a patient, half on a mannequin, which again threw me. So it was, I had to do oscopy on the mannequin head and then I had to do nose and throat examination on a real life kind of simulated patient in the room. And it was just quite bizarre and it was an exam that I hadn't looked at, at all. So I suppose it's just worth, I suppose knowing the main parts to each one. So you can kind of build it all into a general ent examination. Um, so the ear was, I suppose the only, the only part that I felt comfortable with cos it's, it's quite general and it's, you pretty much go up to the ear, say what you see and then you can look inside and as long as you know, your otoscopy, you're OK. So inspect both the ears. So if they've got pain in one, make sure you inspect both and when you're inspecting, you know, it's, it's size shape. I always say any rashes, massive scars and then you can see if there's any discharge signs of inflammation and make sure you check behind the ears as well when you palpate in, it's, it's basically just all the cartilage mastoid process and then your lymph nodes as well, er, with your otoscopy, I suppose the main things just to be noting down is if you're looking in their right ear, hold the otoscope in your right hand and you wanna be holding it like a pen, um I suppose just say you can er, manipulate it a little bit better. So make sure you communicate to the patient throughout. So you should let them know, you know, it may be a little bit uncomfortable but it shouldn't hurt or let me know if it hurts or you want to stop at any time. Just cos they really appreciate kind of good communication through these stations and you wanna be kind of gaining that consent throughout just to make sure that everyone's still ok. Er, when you're moving the penner with your other hand, pull it up and back so you can kind of straighten the external auditory canal and then with the hand that you're holding the otoscope in as you're moving it towards the patient's face, just rest your little finger on the patient's cheek. Just so you've got some stability and you're not gonna, I suppose there's not gonna be any jerky movements of the otoscope which is gonna cause them any pain. Uh And then when you're looking in the ear, so comment on the external auditory matus, first looking at erythema wax foreign bodies and then on the tympanic membrane itself. Um So you're gonna be looking at the anatomy of it. So a handle of malleus cone of light. Um and then it is, it bulging, is it retracted? Cos that lets you know a little bit about pressure behind it. Is there a fluid level, is there a anti media? And then is there any obvious perforation that you can see as well? So this is just a healthy er tympanic membrane and it's a left tympanic membrane as well cos the cone of light always points forward. So that's how I always remember it. Um So it's almost like your, it's like you're looking at a profile of like a, the, the queen or a king on a coin. So you've kind of got the, the, the nose there going out towards the lips and then the, the hair that comes back. So I always remember it's almost like facing forwards, the coin's facing forwards. So the cone of light and the lateral process are pointing forwards or whichever way they're pointing, that's the direction it is, it's left. Um, moving on to the nose. I had never examined a nose before in my life. Um So I found it so weird to try and do it for the first time in an osk scenario, but I suppose it's just following that, that framework again. So you just inspect first and just say what you see, you know, if it, if there's no skin changes, say no skin changes, no discharge, no obvious deformity. Um And then make sure you kind of have a look from above and below as well. Just so in case you can see any changes that, that are only visible from above or below. Er, you can ask the patient to, to look up as well. So you get a better view and then you can use a torch to look inside any, you know, any deviation, any polyps that you can see, er, palpation. Um I panicked and completely missed this. Cos II didn't really know what I was gonna be feeling for, but it's just kind of suppose the nasal bridge and the, the cartilage just under it just to see if there's any tenderness. Um, and then you can always check the airflow by asking a patient to, to block each nostril individually, er, and then examining it. So in the, in the Manchester handbook, it says, I think you use an afters cope, but I think you'd probably be more likely to use a nasal specular which is like that and you, you can use it a bit a bit like chopsticks just to open up the nose. So it gives you a bit of a better view, but it's just commented on, you know, same things that you, you were pretty much saying before. So deviation, foreign body and polyps, um that's nose again, greater throat. So um make sure you're using gloves and a torch. Um and you just wanna ask them to open wide again any visible lymph nodes, um scars neck masses and then comment, aren't I suppose mucous membranes in the tongue. So, is it particularly dry? Are there any excoriations on the tongue, er, oral hygiene in general? And then the tonsils? So you may need to use a tongue depressor for that bit. Um But do they look inflamed? Is there any exudate, are they even present? Er, and then you can comment on the uvula as well. So is it central deviated per patient? You're not gonna be asked to palpate anything inside the patient's mouth, you're not a dentist. Um But what you do need to do is the lymph nodes. So, stand behind the patient and go through in like a systematic way, submental submandibular anterior cervical, posterior cervical, pre and post auricular and occipital um and then your neck exam as well. So that's, that's kind of very similar to what you've just done, but just palpating for neck lumps along the way. So making sure you're checking centrally, er, for any goiters, er, or any thyroglossal cysts and make sure you're checking the, er, supraclavicular space as well just to see if there's anything in there. And, yeah, so that is, that's the, the end of my, er, presentation guys. Thanks for hanging around. Er, I hope you've learned something. I think the, the feedback that we put in the, or the feedback link that we put in the chat. Um, and then if I think if you fill that out, then you'll get the slides as well. But, yeah, thank you very much guys. I hope you find the, er, OSK presentation or OSK. Practice useful. Thanks. I don't know if your ayer facilitators are here yet. Yeah. No worries guys, I'd appreciate if you filled out the feedback cos it's just helpful for me. Thank you guys. Yeah. Amazing. Sorry, I just got kicked off for a second so I couldn't like do all of that. I'll send the feedback formula chat as well. Um, in case anyone needs it. And yeah, what we'll move on to now is the OSK part of the session. So, thank you, Angus. That was actually a really great session. Um I'm sure everyone appreciated that. Um, anyone who's willing to stay back for the OSK practice, stay back now, please fill out the feedback form. Um, and if you want to leave as well, that's ok too. Um, to those of you who are staying, we've got three breakout rooms. Um and it should be on the left hand side of your screen. You'll see the the button called breakout rooms, um, facilitators. And if you guys want to join any of those actually allocate somehow. But yeah, if, if you can join any of those rooms, try and space yourselves out between them. Um And the ci the facilitators will take you through the osteoporosis. Any questions? Just let me know. And Ben, you're, you're welcome to join your session as well. There should be one with your name on it. Ok, cool. Oh, yeah, same for you, Denise. Um There should be a breakout room with your name on it. So feel free to join that as well. If anyone's got any issues, um, feel free to unmute and let me know because the chat doesn't always refresh for me for some reason. So I might not see your messages.