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Hi, everyone. So, um, I'm just gonna start here and then if others are joining us, they can, um, join in as well. Share the night. Yeah. Ok. So hopefully you can see that there. Um, if you can't let me know. Um, so my name is Mairead. I'm one of the, um, peer share committee people, so I'm for Belfast Trust. Um, and I'm just after finishing my assistanceship as well. Um, so yes, I'm going to talk to you today about sort of the key messages for the year three A. So obviously I can't cover everything in it. But, um, I've asked a few of your group kind of what you struggle with the most. So, um, I've hopefully included some of that. So it will hopefully be quite useful for you and give you a wee idea of what to expect, um, in June time. So, yes, my name for that I'm talking about. So the plan is, yes, I'm going to chat to you about, you know, the important information which I'm sure you already know. Um, general advice for the stations, the types of stations you get in third year and then I'm going to take you through some advice for each of like histories, counseling, examinations, procedures, investigation management. And then I'm going to talk to you a little bit about um the resources that I used um or just a new message and as um yes, so it will be recorded um and it will be put up on the metal for you to watch and then I can send you the thing. Ok. Ok. Um Grand. So it, ok, so yes, your important information then. So you probably already know this, but your acies are the week beginning 10th of June, as far as I'm aware. Um, you have six minutes per station, which I think is new to your, your group. Whenever I was in third year, it was five minutes per station. So I think they've just given you another extra minute, um, which we've been like, asking them to do for ages. So that is good. You'll be given like a one minute warning, um, towards the end of your station, which you'll have had in 1st and 2nd year as well and you get one minute reading time and that's also to move between the stations as well. Um, and then as far as I'm aware, it's only for like the, you know, procedures and stuff. And so you'll not have PPP for like histories or anything, but you'll know because of the outside the station. So if it's outside the station do it. Um, so yes, you have 12 active stations across two days. And then as far as I could see on the board office, it's been updated but it said one or two rest stations. So I don't know if you have been told exactly that or not. Um, and then one of the things, so we were doing the Belfast Peer Oy on Sunday there for your year. And one of the things you know, that we were telling people is to only focus on specialties that you've encountered in third year. So I know that you have the progress tests and your MC QS, you're kind of like, it includes like peed psychiatry, all of them kind of topics. But for your third year, ay, just put them topics out of your head. So like p psychiatry and guinea all out of your head. So you're not going to have to do a guinea history. I know we should ta that in second year. So were we, but you will not have to do that this year? There'll be nope history. No psych history. You'll not have to counsel on any, you know, contraceptives or anything like that. And as far as I'm aware, but don't quote me on it. And I've asked the fourth years just to check. You do not have to do any PCD, but I'm not, don't quote me on that. But I've asked the fourth years and as far as I'm aware, that's more of going to be 1/4 year thing for you as well whenever we were a third year, it definitely wasn't going to be on our a um, so yes, and then with that, just try, you know, obviously you are a different um, spec for me. So hopefully this will be as relevant as I can, but it hopefully shouldn't have to change too much of those. Ok. So yes, um, general advice. So I'm sure, you know, like it is a little bit of a jump from second year with the Os, like it's more putting things into like clinical perspective. So in second year, you might have just walked in and done like a cardiac history and that was it. Um But in third year, they were going to start asking you more questions towards the end of it about, do you know what you would do for this patient then if you were their doctor? So it's kind of putting together the clinical knowledge you've gained this year and them skills and there's obviously a few more skills as well involved. So it is a bit of a jump. Um I would say it's probably the biggest jump. Um You do in medicine. So if you're feeling stressed, like that is normal, it's everybody feels like that. Um I remember feeling very stressed for my third year. Oy, because it is quite a change. Um But you will get through it and it'll be ok and you are all in the same boat with that. Um One of the other things we were sort of telling people on Sunday is just like your basics are so, so important. Um, and one of the things that we kept telling people is about informed consent and I know you would have been taught that in 1st and 2nd year, but sometimes it can kind of like go your head whenever you start going on the wars and don't see it maybe sometimes done properly, which it should be, but sometimes it's not. So whenever you go into a station, just make sure that you're explaining to that patient, what you're going to do. So like if you're going to do a diabetic foot exam, it's not enough to say to them, I'm going to do a diabetic foot exam. Is that ok? Because that doesn't mean anything to that patient. So you want to say to them today, I've been asked to do an examination of your foot. What that will involve is me getting you to walk. I'll take a look at your foot. I'm going to feel your foot particularly for the pulses and for the temperature. Um going to test some of your reflexes and test the sensation in your foot, is that ok with you? Um So making sure that you explain that what you're going to do in a way that they are going to understand and even for like histories and stuff, um sometimes people just like jumped into the, you know what's brought you here today, so just tell them you're gonna ask them a few questions about. What is that? Ok. Um So yes, that's just something to bear in mind. And then the biggest thing you can do is to try and stay calm and put the last station out of your mind, there's 12 active stations. So if you are allowed to fail, you know, a few of them. So if you have failed that last one, it's done, it's gone. You're not gonna, you can't go back and change it. So as best as you can try and put it out of your mind and, you know, the rest stations are particularly bad for that because sometimes you can sit and just think about what you've done. Um, but just try to just move on, just forget about it. Um, because if you start to fluster in your acies it, you'll forget your silly things. And so it's just try to stay calm, take a deep breath before you go to the station. Ok. Um, the biggest thing I can tell you is to read the feedback from the 3rd and 5th year, um, acies as well. And I screenshot about the next page and tell you where to get it, but everybody does the same things wrong every year. So if you can read that and realize what you should and shouldn't be doing, then it'll be a massive massive help and they repeat stations all the time. Um They sometimes bring stations from fifth year into third year. Now they always say that take a few things off it because our stations right at the minutes, but there's definitely themes run across the two years. So some of the things that have been on our akie this year for fifth year might jump across to your akie this year. So I would definitely be taking a look at that and seeing, you know what my year did wrong that they're looking for you to do instead. Um And again, remembering your basics. So washing your hands, cleaning equipment and stuff like that, there's marks for that. Um And like if you think about it, you can get the same amount of marks for that as like asking a question in a history, which is a lot harder to do than just washing your hands. Um So we basic things like that make a big difference. Um I already said about the consent technical language is just gone for us except for whenever you're answering questions to the examiner. But like if you're explaining it to a patient about a condition, you don't want to be using medical terms because they're not going to understand it and you may as well not bother counseling them on it and see with whenever you're taking a history from them. Um, like we had a pe station on Sunday and somebody asked me if I had ever had a DVT. Um and to like non medic people that doesn't mean anything. So just using very basic language. Have you ever had a clot in the legs or a clot in the lungs or clot anywhere? Um So just making sure you do that and just remember again about your patient score because it is worth five marks, do you know? So it is a big score. So just showing empathy to them and doing all that and that's what happened this picture in the corner about. So just saying, I'm really sorry to hear that that was very difficult for you. We'll try and get you sorted out, you know, just taking a few seconds to do that and when you get more comfortable taking your histories and doing your um counseling and you have to think less about what to do next doing that. There comes more naturally to you and you're like more cabinet and you're able to like listen to what the patient is saying and saying, I'm really sorry to hear that. Um So yes, and another thing was just don't neglect your year one and two skills. So you can be guaranteed that you are going to get at least one of respiratory exam, cardiac exam or Opto exam. You absolutely will be getting at least one of them. Um And they expect you to be very good at that when you're in third year because you've been doing it since first year. Um, and anyone I know who's failed stations before in, in a year group, it's been on, like, the more like easy stations do you know? Like, I know people who have failed, like, cardiac exam, abdo exam. Whereas I don't know many people, I actually can't really think of anyone who's failed, like, the harder stations. So, if you come out of an station thinking, oh, my, I thought that was really difficult. If the rest of the year thinks that as well, there's probably going to be a very, very low field mark for that. Whereas the ones for like cardiac exam exam actually have quite a high field mark. So just be very, very good at them. And like Queens give you a morphine for them if you go on to the E one and two portal so that you know what exactly what they're going to mark you on. So just be very, very good with that is what I would um advise you and then just remember who you are and where you are. So outside the station, it'll say for example, you are an F one doctor in A&E, you're an F one doctor in GP, you're an F one or you're a medical student on placement in the acute medical ward. So remembering that is very good because it sets you up by at the start of the station and you can walk in and say hello my name is blah, blah. I am this person. Um, and then you're also not like referring to the wrong place. Like I know people who've referred to the place they were in the station. So it just doesn't make sense and you can get yourself very flustered with that as well. Um, always remember seniors, um, any time you ever have to deal with something like at all, scary or serious, say you would ring your senior, um, particularly at the end of histories. Um, I want to ask you, what are you going to do next? A lot of the time there will be a mark for saying I would like to ring my senior and discuss this with them even though you, even if you know the management of that. Um, it doesn't matter like if someone's having a pe you're not going to treat that all on your own as an F one, you are going to ring your senior and say here, by the way, I have someone who is taking a pe I've done this, I think they need this next, um, just to run it by them. So always do that. And then you said about the empathy. So if someone says they're in pain, offer them analgesia say, ok, we'll try and get that under control, we'll give you some painkillers for that. If they say, do you know they're feeling really down about like a new diagnosis, say to them? Ok? I'm really sorry to hear that you've not been getting on well with that. We'll try and, you know, talk you through this and if there's anything we can do, please let us know. Ok, so that it makes a big, big difference. Just they're very, they seem to have very basic points but they make a huge difference to oy. So yes, that's what I said. But the um a feedback. So hopefully you can see my mouse there, but that's it there. So this is for third year. So if you go here three assessment information, additional information and then click onto a and then you'll get this um generic feedback for 2022 and 2023. And you'll also see the past Marks station there. So you'll see the kind of things that people feel um and why they've failed and it also normally says the end but any serious concerns. So like sharps and stuff normally comes up in it. Um So I would say definitely, definitely have a look at that because there is going to be stations that have been done in him years that you will get. Uh and then that's the fifth year one as well. So you can have a look at that um and see what previous fifth years did wrong and you know, we will not do it then in your surgery at all case. Ok. So um practice is practice makes perfect, perfect for us. Um there's nothing that can replace it. Um And the way you practice part is very important as well. So I would advise that you do the time and conditions um because like you should be giving yourself six minutes, you know, or less. Sometimes if you can get it done in five minutes in practice, then whenever you go into the osk and you're like stressed out, at least you have that extra minute to play with. Um and make sure you're including everything in them time conditions. So if you're doing six minutes per osk in your practice, make sure you're including like asking each other questions about the management and stuff and that and not just giving each other like the full six minutes for the history. Um So make sure you do that right? Or else you'll get into bother with the time in those case. Um Yeah, practice with all our medics like people in your class, but also with non medics and particularly for counseling. Um So if you're counseling to another medic, if you say a medic term, they might not clock that you've done that. But if you go home and talk to your family and friends and if you say right, I'm going to counsel you on diabetes. If you say like hypoglycemia or like DK A, they're going to say what's that? Because that's not a term that they're familiar with. So I would say definitely do that. Um Real patients also really good, you know, whenever you're on the ward and you can do like examinations on real patients who have like murmurs and things like that. Um I would highly recommend that um because it even like seeing things on inspection will get, you used to thinking about that when you go into the. So even if you go into Os and they're normal, do you know, you can say I am looking for scars? I'm looking for this, you know, all the things you've seen before in the ward. Um So I would advise doing that. Um some good resources, I'll talk through this again, but you're going to hear me talking about this so much during this presentation. Osk stop is amazing. It's a really, really good book and if you don't have it, I would highly recommend getting it. I use mine the whole way through 3rd, 4th and 5th year. Um It has basically everything in it you could ever need for acies. So I would highly recommend getting that. Um geeky medics is also very good. There are websites that you can go on to. Um like you can look up diabetic foot and gy medics and it will talk you through how to do it. But they also have an ay station bank which you can buy, I think it's like 30 lbs for a year. Um But it's a very, very good station bank because you can sit with your friends and do you know one of the patient and the marker and the other piece of student and you can work through a counseling station or a history station and then you can mark each other on it. It's very, very good. I would highly recommend that. Um And then there are certain things you can practice on your own. So like chest x rays, abdominal x rays, ECG S data in VT fluids, all them kind of things you can do on your own. So like if you don't have that much time to spend with your friends, like practicing. Um oy, I would do these things on my own. Um And then be open to criticism. I, whenever I was practicing my Aussies, I only practiced with people who I knew would tell me if I had done something wrong or if I had forgot something I would far rather sit across from somebody in practicing for osk who told me you didn't do this, this, this, you did this poorly. This wasn't very good. You didn't explain this. You used this medical jargon than someone who would just say, yeah, that was great and not tell me what I had done wrong. So do be open to criticism because if you don't, if you don't change it now you'll do it wrong, nosy and your far rather get it wrong now than on the day. Um And then it is muscle memory. So whenever you're doing the examinations like, whenever you go into the OS, it is just like, just go, go, go, like, you just, you don't really have time to think very much. You just will do what you have practiced. Um, so if you've practiced like the upper motor exam 10 times or 20 times and you know, it really, really, well, you'll just walk into the osk and just do it. Um, and you'll not have to think about it. Ok. So then just a wee note on yellow cards. So I know this becomes like people will be very scared of this, but I know people who've got this and it's not a big deal. Um, it doesn't mean you failed the station. It's normally about something like you didn't put the sharps away in the sharps bin or something like that, you know. Um, and it doesn't mean you failed it. So it's ok. Basically what happens is Queens will send you an email or something and say you got a yellow card. This is it here, this is what you did wrong and then they may or may not bring you to a meeting to just say, you know, just don't do that again. Um, but it doesn't, it's not really something you should be like overly concerned about. Um, like it is you want to avoid them but it's not the end of the world. So if you have walked out of a station and you're like, I didn't put the Sharps in the Sharps fin it's done. Now, you might get a yellow card for it, but it doesn't matter. You probably haven't failed the station and the worst is going to happen is someone in Queens going to tell you put the sharps in the sharps spin next time. So it's ok. And then red cards don't exist like Queens have said that they're not a real thing. So don't worry about that. Ok. So, um the types of stations you get in third then. So obviously you get your histories and then counseling is new to this year. So I'm going to talk you through each of these types of stations a bit more. Um, but you can get counseling conditions or you can get counseling medications and there is like a specific way you can go through these a good structure. So I'll talk you through that um examinations. So that's like a few of them. You asked to do procedures probably you might still get it, but there will probably be less of them um interpretations about one in third year. So we have a good wee bit on that and then management as well. You might be asked not to a certain extent you'd get in 4th and 5th year, but you will be asked some management questions. Ok? So his history is yes, again with the consent just telling them, make sure you ask that before you walk, you know, before you start asking them what's brought you here today. Um It should be automatic and make sure you're doing it when you practice and if you're like testing each other, make sure you listen out for it without just marking them that they've done it. Um, still wash your hands at a history station. There's still marks for it, even though you're not touching anyone, just wash, wash your hands. Um So you know your structure by now. So presenting complaint, history, presenting complaint, and then Socrates for everything Socrates in my mind is not just for pain. Um If someone's tired, I'm still going to ask them Socrates. Um Obviously, some of it won't apply like there's no sight but onset. So when at this start has been getting worse, do you know things like that and then systemic within the history of presenting complaint? You always want to ask people any fevers slash night sweats, any weight loss and any fatigue. Um because that will be like a good like screener for cancer, particularly blood cancers because they can be quite hard to pick up. Um I'm just going to charge my laptop here, so I'll just bear with me for a wee second and OK, grand. Um So yes, I would always ask them them three questions within the history of presenting complaint because that's a good screener for that. I remember whenever we were doing the po in third year in Derry and um there was a patient who had back pain and I don't think any of us got the right diagnosis, but she had myeloma. And if we had have asked, do you have any fevers or night sweats? Do you have any weight loss? Do you have any fatigue? She would have said yes to all of them. Three questions. And that would have been like, oh God, this person probably has cancer. Um So I would always ask that percent. And then your past medical history, drug history, family history, social history, and then ice um try to practice doing ice. Um It should, you know, hopefully just become part of your normal history now. Um So if you're sitting like twiddling your fingers at the end of a station, that's a history, just ask ice at the end. So, um is there anything you think may be causing this? Is there anything in particular you're concerned about? And is there anything in particular I can do for you to say? Ok, it's just three questions. It doesn't take very long and you will get more expert and then if you're very stuck or if you're sitting at the end of the station 100 day, you can start doing a head to toe. Um So I remember I got the thyroid exam in second year. Oy, and I think she come in with like constipation or something and I could not work out what was wrong with her. Um And it was only when I had done a whole history, I then went back and started doing head to toe and then I clocked that she had hyperthyroidism. Um So if you're stuck, hit toe and just like any fits, fits faint or funny turns any problems with the eyes, any problems with the hearing, any problems with the, you know, just a quick run through like that. Um And then something you can start thinking about now this year is driving, asking someone that I would normally ask it under the social history and that's particularly important for like if there's something that would prevent them from driving. So if someone has like dizziness and you think they have like BPPV, it might not be safe for them to drive because if they're turning their head and then getting dizzy, do you know that's not very safe or if you're on the phone with someone, for example, a GP, which they do, do they do phone call stations where you just sit and the person's in the room but you just pretend you're on the phone to them. Um And you think they're taking like a semi or something, it's very important that you tell them I'm going to send the ambulance to, you do not drive to the hospital, don't drive anywhere, just don't get into the car. Um So it's good to start thinking about that. It's more important in fourth year, but it's good to start thinking about it. Now, um, and then now before you go to the oy, I would start thinking about differentials for vague symptoms. So somebody who comes in to you and says I'm tired all the time. There's a lot of things that could be, it could be diabetes, it could be cancer, it could be anemia, it could just be, you know, caused by like their routine. So I would start thinking about the questions you're going to ask them people and practice them histories. Um Osk stop has a good differential list under I guess a history section towards the end of it. So I would have a good look at that for them vague symptoms. Another one is like chest pain because that could be cardiac or arrest or muscle. So, um have a good thing about them and practice them with your friends. And then as I said before, just showing your empathy saying, you know, if someone says I'm having a really hard time with this, just say, I'm really sorry to hear about that. We'll try and get to the bottom of this and try to get it sorted um because it is worth marks at the end of the day. Um And then yes, so at the end of your history, it's now in third year, you'll be asked about what are you going to do next? Um So answer the question, ask. So if they say to you, what examinations are you going to do? Next, don't start saying investigations. So for example, in the diabetic foot, if they ask you at the end of that, what examination would you do in this patient? Next, you could start thinking about like, you know, you could do like ABP, you could check their eyes in case for other signs of diabetes or diabetic complications, but you don't want to say investigation. So it wouldn't be correct if you answered that question with like HBA1C, check your blood glucose because that's an investigation, not an examination. So just make sure you're like answering the questions asked. Um and then I start from the bedside and then work my way up because you're not going to order someone like a CTPA without, you know, doing their bloods or like their s or something like that, do you know? So start the patient themselves, examine them. Um You can say do like an ABCD E sort of thing they are then things you can do at the bedside. So urinalysis, sputum culture and kind of things then your bloods and you say which bloods. So you want to say, you know, I want to get a full blood count. U LFT S um blood cultures, whatever you think, VBG, whatever you think is necessary for that patient and then, you know, chest X ray, then CTPA. So work your way up. Um Don't start straight out with the C TPA because that's not what you would do in the hospital at the end of the day. Ok. And then, yeah, so start with your basic management. Get a senior, if ever in doubt, get a senior, um, give them pain killers for their peeing. Give them oxygen if they're hypoxic paracetamol for high temperatures. Do you know, you start with the basic things and then work your way up because there's probably the same amount of marks for that as there is for saying you get a C TPA for them. If they had like a pe do you know if they're hypoxic, you're going to give them oxygen. And I know it can be hard to remember that in a station and you're very focused on the endpoint, but just remember the simple things because there is marks for them. Ok? So then counseling. So I know this is new to third year and it's one of the things that can cause quite a lot of like panic whenever you're in third year because you don't really know what to do. I remember hearing about counseling conversations in, in third year and I was quite panicky about it, but it turns out, ok, like at the end of the day, you're just going to answer the patient's questions when you're stuck. Um And if you don't know the answer, just say, I'm going to ask my senior and I'll come back to you and here's a leaflet which says, you know, everything in it. Um And give them like good websites and stuff. So if you're not sure and if you're not sure of the answer or something, don't make it up, tell them you don't know. And you're going to ask your senior because whenever we were in third year there was a, um, counseling on P KD and she started asking us about, like, I think it was like, her children's insurance or like her children's like, fact their work and stuff and like, I didn't know I had no idea and most of my year didn't, but we just said to her, look, I'm going to tell you this, I'm actually not sure. I'm going to go and find out and I'll come back to you and this leaflet should have all that information in it. Um And it was grand and all past the station. So just don't make it up. You're better saying you'll come back. Um So yes, he is brilliant for this. It has all like explanations and stations um for this. So if you look up like, you know how to counsel diabetes on um g me, it'll come up how to do it and then you can practice with each other doing stations and marking each other on it. It's very good. Um O you stop under communication, they have like a table of common drugs to counsel on. So they have like methotrexate ace inhibitors, all them kind of things and they tell you what you need to know about them and what you need to tell the patient, including like monitoring, you know, what kind of blood tests and they've done and stuff um which is important to tell them. Um And as I said, practice, practice, practice with the coun consultations. The first counseling station you do as practice will probably be a mess to be honest and it's the same with everybody, but it will get better as you get more comfortable with it. Um And yes, as I was saying, that's a good one to practice on like friends and family who don't really know by a lot about that medication or that condition because if you say medical jargon to them, they're going to be like, what does that mean? Um And you, it'll get, you used to explaining it in very, very basic language. Um, because you're not going to go into the pathophysiology of like diabetes. Do you know what you're going to tell them in very simple basic language? Um Absolutely. No medical jargon as I said before, um, don't be talking about anything abbreviated or any strange words. Um, like as if you were telling a person off the street sort of thing or your mum or dad or wee brother or sister or something. Um, and then chunk and check is very important. So you should ask them like 2 to 3 times in the station. Does all that make sense so far? Is there anything you would like me to go back over. Um, and then yes, driving as well is very important, especially for things that affect it. So, like your diabetes, because if someone's like going to go hypoglycemic, you know, that's not good for driving. So they need to be, their blood sugars need to be five to drive for that. Um, which is a good one to tell them. Um, and, or if you're not sure about driving with it, say to them, the D VLA website is very good for this. I would advise you to look it up or I'll look it up for you and let you know about if it's going to affect you driving, obstructive sleep apnea is another one because obviously they get sleepy during the day. Um And it can be very bad if they're driving then. So make sure you refer them to the D VA website. Um And yes, for the counseling, the most important thing is the structure. So walk in, you know, do your, you know, introductions consent, blah, blah, blah. And then I would ask them what has happened up to this point. Ok. Just to double check that they have been told now in third year, they are going to be aware of it because you will not be expected to break bad news in third year. That's 1/4 year topic. You do that in cancer studies next year. But just to check what they know and that they definitely know that they have that condition. Um, so I asked them what has happened up to that point and they'll probably tell you, oh, I went to the GP with these symptoms and I got diagnosed with blah, blah, blah. I want to know more about it. Ok. Um, and then if they say to them, you know, if they say I've been really struggling with this, make sure you say to them, like, I know that's a lot to take in and it can be very difficult, but we're going to try and, you know, get you good information on today and we'll get you through this and if you ever need us, you know, just let us know. Um and even a good thing to say at the start of the decision, if they say, oh, I've been just recently diagnosed with this, you can say, I know this might be a lot to take in. Do you know how are you getting on with it? And I can just, it's just a very nice thing for that patient then to know that you actually care about what you know about them and how they're getting on. Um So yes, so I acknowledge that and then do ice. So what do you already know about this condition? Is I concerned? Is there anything in particular you're concerned about with this? An expectation? Is there anything in particular you want me to go over today? Ok. So I would always ask them three questions at any stage. If queens don't want you to do that, the simulated patient will just say I have a list of questions for you. Here they are. And then you just let them do that. That's OK. But this is the way I would approach it. Um As far as they let you and then you start answering questions. So whenever they under expectations will say, I want to know like, what, like why have I got this or what is this or whatever? Right? So I'll start answering questions or if they don't do that, just explain it to them and I'll take you through the structure for that next. And then at the, at the end, always, always give them a leaflet, there is a mark for it and it's a very easy mark and you just hand it to them. And if you think that you're going to forget to hand them a leaflet, what you can do is at the start of the station, you can say to them today, I've been asked to talk to you about your recent diagnosis. Here is a leaflet if I forget to ask anything and it's also very good for you, you know, to look, look over, you know, after today. So if you don't think you'll remember to at the end do at the start, OK. So um this is how then I would go about explaining each of them. So um condition I do normally we can probably manage. So N is normal. So, you know, the normal thing, for example, I'm going to show you acne in the next slide. So acne, you know, everybody normally has like little holes in their skin called pores and normally these are clear, right? So that's what's, you know, normal and then what the disease is. So what actually, you know what it is. So for example, acne would be so in this, in acne, what happens is there's overproduction of oil, this then fills these little pores, um bacteria gets into it and that causes acne. So you've covered there, the normal and what the disease is and in very, very basic language. Ok. Um There's no, you don't need to talk about like Sebum or anything like that because that's all very like medically um causes. So you can talk to them about like, you know, whenever you're young, particularly normally like a teenager or whatever. So you can say to them, you know, when you're around that age, there's an increase in your hormones, this increases the oil production. Um So more, more oil means these pores get filled also like genetics and you know, talk about like stuff like that. Um If it's like type one diabetes, you can tell them like it's an autoimmune condition, what this means is basically the immune system in the body attacks itself. Um And then probably its problems for complications. So for acne, it would be like scarring, affecting their self conscious, scar itself, um, effect on their self esteem and stuff. Um, so just thinking about that, um, for diabetes, it would be like, do you know, thinking more, you know, your big ones, like your hypoglycemia, do you know if your sugars, if your sugars don't go too low, if your sugars go too high, um, can cause problems but then also the complications. So problems with eyes problems with kidneys, problems with the heart, um increased risk of like different things like strokes and stuff, um can cause problems in the foot. Um And then when you're talking to all of them about this, especially with the diabetes because there's quite a long list of complications, just reassure them and say, but this can be prevented, you know, and with diabetes particularly, we're going to work together to make sure we keep your blood sugars in the good range so that we prevent these complications from happening and we're going to keep a really good tidy in you and make sure, you know, we get this under control so that these don't happen, ok? And then management so include things you can do. So start basic and work your way up again. So for example, if it's weight loss, like type two diabetes, you can say to them, you know, a lot of the time it benefits people if they, you know, were to lose weight, um, you know, healthy diet, increase your exercise, stuff like that and then include your management. So what you're going to give them if you're going to give them any medications or anything? Ok. So, um, yes, so that's when you include that and then for the medication. But, so I use the athletics. So the action, so what the drug does and that's a very, very basic language. Um, and then timing. So, um, like when to take it how to use it. So you could even just say, you know, it's a tablet that you take through the mouth and you take it once a day, every day, try to take it at the same time every day. Do you know that there kind of thing length of time? Do you know if it's going to be lifelong? You want to let them know that like if it's an ace inhibitor or something, let them know they'll probably be on this for the rest of their life. Um And then the effects. So the effects is like the benefits of it. So why are we giving you this medication? So like an ace inhibitor would be this medication reduces down your BP. You actually won't feel any different on this, but it is working in the background to reduce your BP and that will reduce your risk of clots or reduce your risk of strokes and heart attacks. So that's why we're giving you um tests is like the monitoring, you have to do. So like if you have to check something like kidney function, liver function tests, things like that. Um You would put that in there. Important side effects. So I would just include the big scary ones and the common ones is what I open in there. Um And then contraindications generally they shouldn't if they're not station but you can just say just check and you don't have like any problems with the liver or, or something like that, you know? Ok. So that's what I would use. I have an example on the next thing or this is, you know, some of the examples of kind of things. So you get these lights and stuff on this so you can, you know, see that there, but that's some of the more common conditions and medication should be asked and it is pretty common, you know, conditions like you'll not be asked to counsel like something really rare. Do you know? It will be something you've come across before? Um, and at the end of the day, like if you don't know a lot about it, that's ok because you're only talking about it in a very basic patient friendly language. Like you don't need to know about the pathophysiology of it. You just need to be able to explain it to somebody, um, in a very basic way. Um, and then that's some of the medications as well. Um, they're particularly fond of steroids. Um they like the counseling a bit. And I think the reason for that is because it has so many side effects that you can talk about. So I would definitely practice that and sometimes they bring it up within a station. So like they've brought up nephrotic syndrome before and then within that, you obviously have to counsel them on steroids so they can come up like together. Ok. So it's important to be aware of that. OK. And then, um so yes, this is I've done an example right here. So this is like counseling and acne so yes, do your consent at the beginning. So what has happened up to this point? And then that's when they tell you they have been diagnosed with it. Sorry. Um I know I had to ask them like, how are you getting on with a new diagnosis? I know it can be a lot to take in and then your ice and then do your normally we can probably manage. Ok. And then within management, then you can do your athletics, I think its a leaflet and then that we read is just where for example of where you can do like junk and check. So after you've tell them, told them what it is, just say to them does everything I've said so far. Make sense. Do you have any questions about anything I've said? Ok. Um Because at the end of the day, like these kind of sensations. It's more important that they walk away understanding than you just like spew information at them. Ok. So important to remember that. And then that's one for like, um, steroid counseling. Oh, no. How long? I think that actually should be statin counseling. Sorry, I'll change that. That's both statins. Um, so yes, for example, you know, you just again your brief history, your ice and the end that your athletics. So, you know, take it at the same time to take through the mouth once a day, at the same time, every day, take it at night time, you'll be on it lifelong. Ok. Um So yes, and then just always give your leaflet again. Ok. So onto examinations and um so hopefully that makes sense so far about the um counseling. So if you have any questions about that, you can fire into the chat or, you know, it really is just about practicing it um and getting comfortable with it because it is new. Ok. So um examinations, as I was saying earlier about the consent, do you know walking in and saying I'm going exam isn't good enough. You need to say what that will involve. OK. And like very basic language. Um ask them about pain as well. When I was in third year, I put like a post it note and it literally said just on it, ask about pain. And I, I had that right beside my bedroom door. So every time I left my bedroom, I saw this ask about pain and it drilled it into my head. So whenever I came to the last case, I asked about pain for every examination because if someone has a sore shoulder and you're going to start moving around, you want to be aware of, that's sore before you move it. And then also, like, if you're doing a bowel exam, you go to the painful area last. So it's just important to remember about that. Ok. Um chaperone, yes, extremely important for anything that you're like if you're at all, if I get a chaperone. So breast exam absolutely needs a chaperone, femoral pulse. You're going to say to them, I'm going to get a chaperone into the room. It'll just be one of my colleagues who's just going to come in and just observe the examination. Ok? Um Chest exam particularly unlike a woman, like if you're going to be exposing them, you need to be getting a chaperone into the room. Um Yes. And then inspections, it can be very easy to just like move past it, but always remember to do that. And as I was saying, outside it inwards. So around the bed, the patient and then focus on the system and then for like cardiac and respiratory, I went like tips of the fingers up the arm face and then down to like the chest. Um So having a system means you won't miss anything. Um Comment on your findings. So like if you listen to someone's chest, you need to say what you hear. Um Because there's no point in listening to their chest if you're not gonna like know what you've heard. So a lot of the time like in a land it will be normal. Um And also for a percussion say what you hear with that. OK. Um Very important that you do that um or like muscle power as well. You'll want to say that that's like five out of five. OK? Um If it involves the light, get them to walk when in doubt. Um And it's very easy to forget, but if you just put that in your head, if it's anything to do with the lower limb, I'm going to get them to walk. OK? Like diabetic foot, peripheral vascular disease, uh motor exam of the lower limbs, get them to get up and walk and observe their gait and comment on their gait as well. OK. So say what you say and then if you're stuck, just go back to your basics of what you're taught in 1st and 2nd year. OK. So whenever we were in third year, we had the cerebellar exam and we were not very familiar with it. So, but what I did, I remember standing outside the station and I just said to myself, well, this is just a neuro exam. So at the end of the day, I'm going to inspect, then I'm going to assess their tone, then their power, then their coordination and then their reflexes and if there's something they don't want you to do, they'll probably tell you no, that's not required. So when you're stuck, go back to them basics. OK? Um And then the scales listen to your log book, any of them can come up and whenever I wake up cerebellar exam, they just said that's in your log book. So you should know how to do that, which is fair enough probably. Um So look at that list and then the Osk stock book is amazing like that. I think it's page 37 has all the examinations on it like a list of them. So I would just learn them as best as I could. Now, obviously, you don't need to do the pediatric ones up and gain ones any of them. But I that's relevant to third year. I would be learning them very well. OK. And then this is some examinations that I was thinking you might need to do. So there's this and then there's another side. So like cardiac exam, pulses exam, which we got in third year, a pulses exam, um peripheral vascular disease, which we got in third year um respiratory exam, cranial nerve cerebellar exam, which we got in third year, upper motor year on lower motor. Um and then theology, they'll probably not get you to do like the whole thing, ophthalmology. They'll just, they'll say outside the station, what they want you to do, like inspect the pupils and then into the fields. Um and it can be easy to forget to inspect them when they've asked you to do specific things. But there will always be marks for that. And again, I work outside Edwards. So looking around the eye, looking for any redness, any swelling, any discharge, then eyelids look and see if they are swollen, prostate ectropion, ectropion, endion, ectropion. And then looking at the sclera, any bloodshot, any, you know, any sub subconjunctival hemorrhage and then looking at like the iris and then the pupil for any irregular arteries in the pupil and you've like you've went through everything you can there. Um So that's how I would do that. And then yeah, I think it's the os topic says like afro so a feels reflexes and ophthalmoscope. Um but they will normally tell you that queens will tell you which ones they want to do because you couldn't fit all them six months. Um ent then nasal exam, oropharyngeal exam, neck exam and ear exam. Um So we got in finals this year, we got a station of all of them. Now you'll not have to do that because our stations eight minutes. Um but you could get some of them. We got the ear exam in third year and we got the ear exam and then a video of the dex hot remover or maneuver and we had to just talk through it, like explain what we saw and what was going on and stuff. Um So they could combine it with something like that again. Um But they're very easy examinations, like particularly the nose and oropharyngeal. Like you just take the wee do you know Orosco and you just look like, inspect on the outside and look in, look for any polyps, bleeding scars, anything like that, same with the oropharynx, like just again, work your outside and you can't go wrong. So I said, you know, looking around the insides of the cheeks, looking at the dentition, looking at the tongue, looking at the tonsils and the soft pod, hard pod looking for XYZ, you know, you're not going to go wrong if you do that, you're going to cover everything. Um And then your, your exam. Yeah, you'll be your thought as well. Ok? And then endocrine. So ones I was thinking of like thyroid exam and diabetic foot exam and then GI abdo exam pr which you should be quite familiar with M SK could be hand shoulder, I don't think they gave you elbow because there's not a way out to it. Um, shoulder or spine, spine we got in third year and again this year and so they seem to be quite fond of it. Uh hip, knee, foot slash ankle. Um So we'll just be aware of all of them and then dermatology. So you could just get, you know, I would say the, the way I might do that is like a DERM history um or like a DERM counseling. And then at the end, they show you a picture of like a lesion or a rash. And you have to describe it, I would definitely practice that because it's really difficult actually. Um and practice rashes and lesions because the two of them are very different. Um like when you're trying to go through explaining them. So I use this here. So sight size, shape, color associated secondary changes, morphology and margins and what that is. So, sight and size and shape is obviously, you know what they are. Um And then your color associated secondary changes is like ification, um like scarring um excoriations, you know, things like that there. Um The morphology then is um like that you're a maculopapular kind of thing. Um And then the margin. So is it irregular, regular and then for pigmented lesions, you do ABCD. So you're looking asymmetry borders, are they regular colors? How many are there? Uh D is a diameter and E is evolution. So, has it changed recently? And that's your screening for malignant melanoma? There, there's a wee message in the chat um when you're asked to describe a germ lesion, is it to a doctor or patient? Um So I would say it'll probably be to a doctor like, you know, to your examiner. Um It'll probably be, you'll talk to the patient about their history or the counseling and then the examiner will hold you, give you that and say, explain or describe this to me. Um So you can and you will use your technical language there. So you will be talking about a maculopapular rash or whatever. Um So yes, that's we we go about that and then other examinations. So your breast exam, male, external genitalia hydration status, nutrition status and just be aware that they could give you a real patient for the breast exam. They've done it before. Um So don't be like shocked if that happens. Um In endocrine, can we get cushing's acromegaly et cetera? I would say extremely unlikely. I know that it's listed in the OS topic but, but I would say it's extremely unlikely you can have like a very quick glance over it, you know, just in case, but it's not one I would be predicting for you. Um So yes, that's, I think if you go through these here, they would probably be the main ones and then just have another look at that osteo topic just in case I ate them. Um OK. And then so once I was asking you a year, like what kind of examinations you struggle with? So what I was told was the peripheral vascular disease exam and the diabetic foot exam. Um So I'm going to go through them a bit with you now. So the peripheral, the way you do it is just try to, like, you know. Yeah, categorize it into like, parts and then it'll be easier. So, um, peripheral Foster's exam we got in third year and it's normally just the lower limbs. So they'll tell you outside, only do the lower limbs. Um, which is grand. Uh, it, it's actually quite, it's not too bad of a station, to be honest. So you inspect and it's very important inspection. Um, there's quite a lot of marks for it and the way I would do that is go distally and approximately so start at their toenails, look at their toes in between their toes, which is rotten, but it has to be done and then up their foot looking for any like changes and just know what you're going to say. So have like a week spiel ready for that. So say like I'm looking for any signs of like, you know, shiny skin, any hair loss um looking for any pallor, just, you know, have a wee looking for any ulcers, obviously be a big one and make sure you look at the bottom of the foot as well for that on the back of the heel. Um and then palpations. So temperature full time and then the pulses. So femoral pulse, you know, chaperone, um they made us do the femoral pulse in third year. So don't be thinking they won't get your date because they got us through and just be quite good at like explaining that to the patient about what you're going to do. So what I said to my patient was next, I'm going to feel the feel for your pulse, which is just located between your groin and your waist. So it's just halfway between them. And what I'm going to do is I'm just going to lightly place my fingers halfway when you're in your waist and your groin just feel that pulse. Um I will be getting one of my colleagues into the room to act as a chaperone during this just to observe the examination. Is that all OK with you? Ok. And then you'll get them to like either pull up or pull down their shorts slightly um to that area and they got us to feel their pulse. Um So yeah, so don't say I would feel for the thermal pulse. They expect you do um pole tail, which you'll never feel. And if you don't feel it, tell them you don't feel it. You can't lie. Um because they'll have probably examined them beforehand and they'll know rightly, there's no way you felt their pople tail pulse, you're lying um posterior and then pedis and just know exactly where they are. So you're not like fiddling around and penis. If you get them to flex their big toe upwards, it should be just lateral to that. Um And about halfway down the front. Um but look it up online, you know, check it on yourself, do all that there. Um and just be very familiar with that. Ok. Um And then grow sensation. So for peripheral vascular disease, I would just do it with my finger or whatever and then, and start distal. So if they can't feel it at the tip of their toe, then move up. Ok. And then at the end, they'll probably say, like, ask you what further examinations would you consider doing with this patient? So you can say burgers, which is where you lift their leg up to go to peel, that's burgers angle and then you turn them around, they sit on the end of the side of the bed with their feet dangling over it and you're looking to see if it goes red and then pale again. OK? Or B um and then ABP is your wee pressure index. So you take your BP in your arm, your BP in your leg and you see what the ratio between them is. So just be here with the ratios for them. So normal is 1/1 0.2 is like a sign of calcification. So sometimes diabetics will have that. Um And then I think it's 0.8 and lower is side of peripheral vascular disease. Ok. So another two questions would you wear gloves while doing um any of these examinations? So I would say if there's gloves outside the station or in the station, I'd be putting them on. Um I think I'm trying to think back to even our oy this year, I think they did get us to wear gloves for examinations. Um, probably, and if it's a foot probably will get you to, you know, wear gloves for that abdomen. They might not chest, they might not. Um, but if there's gloves outside the station in the station, put them on, um, would you be expected to do burgers test or would they say we do not need to do it? Um So there are mixed reports of that from Mar or whenever we did it. So I said I would do burgers, you know, they asked you, what examination would you do next? And I said burgers and she said that's OK, you don't need to do it. But I know other people, the examiner got them to do it. So obviously there was no marks for it and that was like the, you know, problem with the examiners, but I would just be like familiar with it. It's not that hard then, you know, you just have their foot like that, you know, lying in the bed, lift their leg up until it goes pale. That's burger's angle, the angle at which it goes pale, then, you know, put them over on the side, you know, they're sitting on the end of the bed feet dangling, looking to see if it goes red and then back to normal. So it's not too difficult to do. Um If they do ask you to do it. Um Not a question there, chat. Um The a topic has a lot more detail and extra steps and the Queen stops from 1st and 2nd year, which do we follow? Um Is this for like, you know, the cardiac exam and respiratory exam and stuff like that? I, so what I, the way I took that whenever I was doing it was that we marked each other using the Queen's one. But the osk stop was more of like a good insight of like why you're doing each of them things and how exactly to do it. So on the Queen's Mark scheme, it might say, you know, checks, the heart sounds, checks for murmurs. Um but for examinations, so the a stop book will then tell you exactly what to do and how to do it. So yeah, whenever we maring each other, we use the Queen's Mark schemes but read through the topic. So we like, understood what we were doing and we were like, very familiar with it. Does that answer your question? Um So yeah, kind of a mix between the two. Ok, great. Um Yeah, mark each other with the Queens but definitely go stop because it is, it gives you like good tips and stuff for the examinations. Question there for diabetic foot and one in a stop, the neuro exam is just sensation. Whereas knock on Sunday, there was also lower motor, it was just Well, in neuro exam, it's just sensation. Oh, hold on for diabetic foot in o and your exam is just sensation. Whereas in locks and so there was also lower motor. Which one do we do for the Os? So, as far as I'm aware, I was going to go through diabetic foot with these next, but the motor part of the diabetic foot is you just comment on if you see like any pe planus or sharp's joint or anything like that. So you're not actually getting them to physically do anything. You just look at it. If you look at the osteo topic, I think it says under motor, just shortcuts joint and like looking for that inspection wise. So that's what I would do. Um, you definitely wouldn't have time to do like a full lower motor neuron exam on them in the six minutes and the diabetic foot exam. Ok. So, yes, this is diabetic foot exam next. So, um, first of all, get them to get up and walk. Um, because if you don't do it at the start, you'll probably forget to do it and while they're up and walking and look at their shoes, so you want to look inside their shoes and see if there's any like stones or anything like that because if they, if they have like diabetic neuropathy, they probably won't feel it if there's a stone inside the shoe and they could like, wreck their feet. Um, so just looking inside that and then looking at the back of their feet or the back of their shoe. So the sole of it and seeing if there's any, um, like uneven wear or anything. So that's what you want to look for. Give them sit down and then, or lie down and then inspect the foot. So again, start this approximately, start at the toes, looking at the toenails, any problems with that, any like missing toes, which can be quite surprisingly, you can miss it in an ay. Um So just make sure you do that and then looking in between the toes, looking for any ulcers like at the bottom of the feet, looking for any ulcers there. And if you come across an ulcer, you need to describe it. So, um because it could be or an arterial ulcer, a venous ulcer or a um neuropathic one. So just make sure you're like explaining it if it's like the size of it where it is, you know, you can basically go through which of the SSS CC CSTD DS um are applicable there. So just go through that. Um and then palpate. So this is quite similar to the peripheral vascular disease exam. So again, temperature, peripheral time pulses and then sensation. So you don't use a neuro tip for this. You use the monofilament and this wee thing here, see the way it says 10 g, that is the monofilament that you will use OK. So you just slide it down and you press and I have a doubt from here of where we were taught to do the areas. Now, different places say different amounts of places in different locations, but this is what we were taught to do. So, two on the toes and then three on the ball of the foot. Ok. And that'll give you a good idea of if there was, do you know that person had neuropathy or not? Um And then vibration. So you're tuning fork. So use that and then reception. So make sure you're getting them to close your eyes for that as well. Um After you've shown them, get them closer eyes for all the sensation because obviously if they see you touching your foot, you know, then there's no point in, in it. Um And then for the reflex, this is just the ankle jerk reflex. You don't need to do the knee jerk unless they're missing the ankle jerk or something like that, you know. Um And for the sensation, if they don't have a vibration and like the big toe move up the way, so you start the big toe, the MT pee and then you move or the inter inter Yeah. So you, you go from the toe down to the um MTP, then to the medial malleolus and then the knee. So just move down your joints. Ok? Um If they can't feel it at the previous one, OK? So hopefully that makes sense for that. So yes for yeah, for motor for this as it says in stop, I don't even have it here because I've written cu joints there. So just ask what I be doing, just comment on inspection for that. Ok. So procedures, so that's the examinations I was going to go through. Um because you know, there's quite a lot of them but a stop is very, very good for them. And if it's not answering your questions on it, Metics, well, because it's more detailed um and it has like all of the examinations you could be ever asked. Ok. So then procedures, so only is BP measurement. Um I think it's unlikely but do be familiar with it just in case your analysis they made us do in third year. Um So be familiar with it. Um And there is quite a few particular things you remember doing it. So checking the expiry date, checking the patient's details, waiting, the correct amount of time, see what you see. But there's a dots on that, you know, on the Queen's portal. So just making sure you're familiar with that and what you're doing and blood glucose measurement technically could get you to do, don't think they would. Um And then like taking blood cannulas catheterization is very unlikely to come up. Um partly because the equipment is very temperamental. Um So they don't know if it'll work for everyone. And also if they were going to get you all to catheterize a don. Like that's a serious amount of equipment for 300 people. So, if catheterization was ever going to come up, I would say it would be like flushing a catheter. I don't think they would get you all to insert a catheter and also would take more than six minutes. Um And if you think about all the aseptic techniques and changing your gloves twice and stuff like that, I just do not think that they would do that and they haven't done it since I started Queens. So I think they're very unlikely and they're also tested in the law book and that. So I think it's OK. OK. So then interpretation so becomes a lot bigger in third year now. So you will definitely definitely get stuff to interpret this year. Um So every single time they give you a sheet, you always, always, always check the name, the date of birth and the health and care number because there's a mark for it there. And it is very important that, you know, you're looking at the right person and stuff. Um And there might be like an arm band sitting on the table now for purely interpretation stations, it will probably not be a simulated patient, but they might have the arm band sitting on the table. So just check it against that. Um And then it's actually quite simple, like a lot of them, you just say what you see and then if it's high, normal or low, particularly for like the news charts and stuff, like you're just going to say their respiratory rate is 25 that is high, they are scoring whatever for that, you know. So it's just working your way down through it. OK? So this is some of the examples I was thinking they could give you for interpretation. Obviously, that's not an exhaustive list but like chest xray, abdominal x-ray, ABG S ECG S. We got an ECG station in um third year. We had a semi um pulmonary function test. They could give you at the end of like a respiratory history or something news charts will definitely come up um and fluid balance chart. So just be familiar with all of them. Um So I've went through like how I go through uh chest X ray. So I'm sure you have all heard of like, you know, Dr ABCD. Um So that's what I use. So details and you're doing the patients, details the details of x-ray and then you want to compare it to previous X rays. Anytime they give you a chest X ray, abdominal x-ray or an ECG, always say you want to compare it to previous ones to for changes. Um Have they ever asked to perform an ACI don't think they have like technically they could get you to, but I don't think they would. Um partly because doctors hardly ever do it. Um, and I think it would take very long and then sticking on them stickers and you have to put the stickers on and rip them off that person's chest like 10 times in a row. I just don't think that would come up. Technically could, but I think it's very unlikely. Ok. So, yeah, so you're doctor ABCD. So ask for previous things for a comparison. Um, anytime you're not at one, even like an ABG, you know, if they had an ABG done this morning as well, we want to look at, see what that one was like to see if they're getting worse or getting better. Um And then, so r is radiograph quality and sometimes people like their way through this but um because they know they need to talk about rotation, inspiration, penetration and enough included, but they don't actually know what it is they're looking for, they know that they are things so just be quite clear with what you're talking about with there. OK. So the rotation is that the spinus processes is equidistant from the medial health of the clavicle, which makes sense because if your clavicle sitting like out there, whatever it's going to be like off, OK. So you're not going to your clavicles for that um inspiration. You want to count the number of ribs. So you should see plenty of them. Um And that's just to take a good inspiration. Um penetration, you see the spinus process through the vertebra and enough encl. So you see above the clavicles below the diaphragm. Ok. So you should see the whole of their lungs and below the diaphragm. All right. And then you just go through your ABCD. So your airway. So you're looking on the tria, is it central or deviated? Um, and try and learn that different things, you know, that can deviate your trachea if it's like pushed away or pushed towards, um if there's like an obstruction there. So like someone inhaled something, you know, you could see it there, you look at the car to see if it goes like that. Um And then the bronchi, so just down like that there, ok? Um Breathing. So I would do lungs top to bottom and you're comparing each side, ok? And if you can't see, to be honest, when you had a chest X ray in a, it's more than likely going to be something wrong with their lungs. So if you are sitting and looking at this and you're like, I really cannot see anything wrong with this. Take like a, you know, go back a bit and just look at it like from distance because sometimes when you're sitting up close to it, you don't always see the abnormality. So just physically step back a wee bit and look at it again, ok? But compare right to left as well. Um because that will help you and then look at the hila and then trace around the lungs for the pleur up because you could very easily miss a pneumothorax. Um So just do that. So it's there and then around, ok. Um circulation is your heart. So you're looking at the heart side and that's only on a posterior anterior because you can't do it on ap because you get the cardiac shadow. Uh So the heart should be 50% or less of the diameter of the chest. Um So you're looking for cardiomegaly there, but only if it's um pa A um and then you're looking for your heart borders. So just make sure they're all normal. Um your aortic knuckle and then your aortic pulmonary window is there as well. Ok. So you should be able to see all them properly. Um If you can't see the heart borders or anything like that, it could be, do you know that person has like sometimes pneumonia or something? It just makes it because it sits over it, it just makes it all very like blurry around it. Um So you could pick up it by looking at the heart borders. Um, look on the diaphragm then and the cost phrenic angles and make sure you're looking just onto the diaphragm as well because if someone has like a new parent name from um like a intestinal obstruction that is perforated, it'll give them pneumopent name and that's a very, very important thing to pick up. Um, and make sure you're able to differentiate newer name from a gastric bubble. Um So gastric bubble is on the left and it's inside the stomach, whereas pneumopar name is just under the diaphragm. OK. And then the Clausen angles are good as well. So sometimes they can be a bit blurry. Um and that there could be like a, you know, a uh pleural effusion or something there. Um So just keep an eye out for that. Um Can we get an M SK x-ray? Very, very unlikely. It's more fourth year for fractures, they would give you that um like a dislocated hip or something and you don't do fractures in fourth year or in third year. So I would be very, very surprised if they give you an M SK X ray this year. It's more chest and abdomen, particularly chest. Um We've got a chest X ray, we got one in third year and in fourth year. Um So our one in third year was just a pneumonia and then fourth year was a pneumothorax. Um So yes, just be very good at them, I would say and look at loads of examples of different things like pleural fusions. Um pneumothorax is um and pneumonias. And then the last they asked us then like, how do you treat it? Like, what would you do for this patient? Um which is where like your oxygen and stuff like that, do your curb 65 scores, things like that you want to say, ok, sorry. Um So that's D and then e is everything else. So the bones. So you want to see the ribs because say like a broken rib or whatever you want to know um tubes if they have any like endotracheal tube in or whatever, any valves, any lines like the ECG stickers or something like that, even if they have like, you know, the zipper on their fleece or whatever you want to say, oh, that's not what, what that is. Pacemakers. You might see things like that. So just come on anything abnormal. Um And then review areas. So that's just areas that you can very easily miss something. So you should be going back over these. Um So it's a lung, a disease, retrocardiac area, the um pain, the diaphragm and then the peripheral regions of the lungs, as I was saying, like people sometimes miss Serax and then the hila as well. Ok. And um and that's just an example of a chest X ray. So you can go that out yourself. But you know, you do your patient details that we sticker on the left there just to show that that's the patient's left. Um And then you just work through, you know, you work through your right. Um And then you a so you're down your by sex there at the um thing and you can see the bronchi there and then no obstructions around central and then you just go through um, your lungs. So you see there that, that is like a long t that person has. Um, and even whenever you get to the abnormalities still go through like your CDE. Ok. That's just, you can see just at the bottom there, see that wee like light area at the very, very bottom. That is the GB. Um, so that's normal, that's fine. Um, but if it was like higher up and just under the diaphragm, you'd be worried that that was like a name. Ok. Ok. Um That's grand and then abdominal X ray. Um less likely to get, but definitely do go over it. It's a lot more simple. Um So I use Dr Bob for it. Um So details again and then your radiograph quality, which is just your right and then the bile. So the small bile, the large bile, um and then the diameter of it. Um So small bowel is three centimeters colon, six centimeters CS nine. Ok. So if it's any more than that, it's, um, it's likely that person has like bile obstruction. Um And then your organs. So just literally name every organ you can think of to say I'm looking for the kidneys and I cannot see them. I'm looking for the gallbladder and I can't see them. I'm looking for the liver. I can't see it, you know, I'm looking for the bladder and I can't see it, you know, so everything just go through it and marks, OK. And then your bones again. So particularly like the, if you can see like the pelvis or whatever, just saying you're looking for like any fractures or anything there, even though you don't know what that would look like that you're not going to have one in third year. So just say that's what you're looking for. Um And then everything else. So artifact, any calcification like stones, surgical clips, anything like that, anything abnormal looking, even like the zip, burn their genes, do you know? Um So that's an example there of bile obstruction. OK. So you can see it's all like dilated up and you would talk more about that. OK? And then you can see them, we two artifacts there at the bottom as well look like meals or something. I don't know what they are. OK. Um So then ABG is next. So uh you can get this as well and they'll just give it to you and be like you interpret that. Um So the first thing I look at is the ph because that's going to tell you if this is acidotic or alkalotic. OK. So if it's up, it's um alcoholic and if it's down, it's acidotic. OK. So that's the first thing. So you've, you've decided that? OK. And then look at the PA O2. So are they hypoxic? And remember you want to take into consideration if that person is on oxygen because if they're on a pile of oxygen. Their pa O2 should be very high. Um, but quite often if they are, it'll be low. Um, the PA CO2. So if it's up their whole non carbon dioxide, if it's low, they're getting rid of it. Um, and you want to know if you want to work out, then if that is what's causing their ph to be abnormal or if they're trying to fix it with that. Ok. Um, the bicarb, then, so if it's up going on, let down getting rid of it and that's either what's causing the abnormal Ph or is there a way of trying to fix the ph? Ok. Um The BS, then I wouldn't really worry too much about it, but it's to do with like carb. Ok. Um And then it's just important to know that an ABG also shows you their glucose. So for example, like if someone has, you know, diabetic in DK A and they're like extremely acidotic and you're wondering why their ABG will tell you everything because it will tell you, you know that their ph is down, so they're acidotic and it'll tell you that their glucose is very high. And then the only thing you need to test off that is your ketones. So it will tell you the cause more or less. Ok. So it's important to know that there, it will also tell you their lactate. So if someone has like a bile obstruction and their bile is dying. Um It'll tell you their lactate will be up, so they'll have lactic acidosis. So that'll be able to, you'll be able to narrow down your like differential list then and then it also tells you your potassium as well. So, what I always do is I always remember this wee thing which is Rome. So, respiratory opposite, metabolic equal, right? And what that means is that if it's respiratory element that's causing the abnormal Ph, the PH and the respiratory element will be going in different ways. Ok. So if the PH is up and it's caused by a respiratory problem, the CO2 will be down. OK? And if you think about that, the reason for that is because CO2 is acidic. So if you have too much CO2, it goes up, your ph will go down because it's acidic. Ok? If they have not enough CO2, like if they're blowing it all out like in a panic attack, um it's going to go down, there's less aet about so their ph is going to go up. OK. So if the ph and the CO2 are pointing in opposite directions, it's a respiratory problem. OK? And then at metabolic it's equal. So the p in a metabolic problem, the PH and the bicarb will point the same way. OK? Because it's like an alkaline, OK. So if the PH, if the bicarb is up and they're holding on to bicarb, then that's more alkaline is about. So the PH will also go up if their bicarb is down because they're not producing enough of it or they're getting rid of it. Sorry. Um Then their ph will also go down because it's more acidic. Ok. So that's the way I remember it. Um And if you do that, it just makes it a lot easier to interpret. OK. So a wee table on this, the next page. So obviously your oxygen will be there too and it can help you with determining if it's respiratory or not. Um But if you look at this here, it will help you. Now, there is obviously you have to think about like if it's compensatory or not. So if it's a metabolic problem, the P AC two will kick in quite quickly because you can change your breathing very quick. Um So they will normally kick in quite quickly. Whereas if it's a respiratory problem, it will take a little while for the bicarb to start trying to fix it because obviously, it's quicker for you to start breathing differently than it is for your kidneys to start deciding how much bicarb, you know, you're going to hold on to. Um So that's why if someone comes into the hospital and they're in respiratory acidosis and their bicarb is up, they, that problem has been going on for a wee while because they have had time to try to fix it. Ok. So that's what, how, you know that, that is a chronic problem. Ok. Hopefully that all makes sense. Um But if you follow that wee respiratory opposite metabolic equal, I think it really helps. Ok. So I have a wee example for you now. So as a 64 year old gentleman with a history of CO PD presents with worsening shortness of breath and increased sputum production. So this is his ABG. So his ph is 7.2102 is 7.2 CO2, 8.4 bicarb 29 and the base excess is plus four. So I want you to think about what does the ABG show and think of a differential diagnosis for him. So I'll give you a wee second to think about that. OK, we'll go through this. All right. So, so you want to look then the PH, so it's down. So it's acidotic, their O2 is down. So this person's hypoxic. So it's probably going to be a respiratory problem. Um Their CO2 is 8.5 which is up. So if you look, then their CO2 and their PH are pointing in opposite directions. So this is the respiratory problem. Um their bicarb then is up. So it's high and the base excess is up. So it's high as well. So this is how you know, this ABG shows type two respiratory failure with partial metabolic compensation. The reason it's type two respiratory failure is because the O2 is down and the CO2 is up. So if it was type one respiratory failure, it would just be a problem with one of them. But type two. So type one, there's a problem one and type two problem with both of them. Ok. Um And then you know that it's caused so it's a respiratory acidosis because I was saying about the, do you know the two of them is different? Um And then partial metabolic compensation, we know that that's happening because the bicarb is up. And the reason why it's only partial is because that has not fixed their, their ph, so their PH is still low. So it's only partial metabolic compensation. Whereas full metabolic compensation, their PH would be normal. Ok. There's a wee question there when you're asked for a differential diagnosis, do you have to say it more than one or is well enough? They'll tell you um Queens love to take your first one. So if I was going to a differential, I would do my most say my most likely first. Um But sometimes they'll say to you give me three. So for example, on this one, I just wrote in fact, of exacerbation of COPD because that's the most likely one. But you've got to come up with a few other ones, but just make sure with Queens, you're saying you're most likely one first because sometimes they'll just take your first answer. Um which is very annoying. But um so they'll tell you how many you want? Um and say you likely first. OK. So um ECG then, so it's good to have like a structure for this as well. So the way I do it is the details. So again, the patient did ECG and then the calibration, it'll always be 25 millimeters per second. OK. So it'll always be that, but just say you're checking that. Um then I do rate rhythm axis and then just follow along the complex. OK. So the rate, if it's a regular rhythm, you can do 300 divided by the number of large squares from R to R. OK. So if there's like three large, you dividing that by 300 their rate is 100 BPM. OK? Um But if it's irregular, so if there's does that makes sense because if there's like a difference between the length of, between R and R that's not going to work, that's not going to give you an accurate rate. So what you do is you count the number of complexes on the rhythm strip and you multiply it by six. OK. So that's, so just learn that um rhythm then is either going to be regular, regularly, irregular or irregularly irregular. OK. Um And you're going to want to count the number of squares between the RS. OK. So if two of the RS have like one square between them and then the next one has three squares between them that's obviously an irregular rhythm. OK. So just be aware of that. And then in third year in, in, um, ECG si think they're probably going to give you one of three. if it's not normal, it'll be either a semi, um, an af, or hyperkalemia. OK. So it is more than likely going to be one of them three. The reason for that is because I don't think they're going to give you like B FB or any of them kind of things because that's more A&E next year. Um That's not to say they couldn't and they, you know, won't, but I would say my bet would be on one of them three. We got a stemi ECG in third year. So I would be very familiar with M three. They're probably not going to give you like bundle branch block or anything like that in OS. That would be more like M CQ because it's very hard to do that in an Os. Um So just be quite familiar with M three and then the cardiac axis. Um So you can look this up kind of the difference between them, but basically lead one is positive. Lead two is very positive. And by that, I mean, the, the QR S complex goes up um and then lead three is negative. So the QR S complex overall points slightly down and that's just to do with the way the heart is beating um like the whole electric current goes through it. So you want it obviously to be, you know, going down through it. So that's normal. Um And then you can have like right axis deviation, left axis deviation. I wouldn't get too bogged down on that. Um, and it's unelected to come up in your oy. But you can say you're looking at it and say lead one is positive, bleed two is more positive and lead three is negative. Therefore, the cardiac access is normal. OK? Um And then just follow along. OK. So the P waves are there and A they are not going to be present and then is each P wave followed by tr because if it's not, that's like that's a block. OK. Um And then the pr intervals should be 3 to 5 small squares. So just count them. Um And if it's more than that, then you're thinking a block. Um And then the QR S complex. So how long you know the width of it? So it should be less than three. So squares, the height of it, if it's very high, it could be like show like ventricular hypertrophy or something. Um And then the morphology. So AQ wave is just like a wee wave like down like that at the beginning of it. Um And that's a sign of previous M I and that will never go away. So joy like ST elevation on a semi eventually that will go away on that person's E CT, if you do an E CG in like a month's time, they won't have that ST elevation anymore, but they will always, if they get Q waves, they will always have Q waves. Um And then our wave progression just means it gets like bigger as you go from V one to P six. OK. So that's normal. And then your delta wave is like a wee up slurred wave at the beginning of your QR S complex. I wouldn't worry too much about that. They're unlikely to give you like a delta wave or something um be very obscure, especially in a. Um But yeah, so just say you're looking for them things and then your ST segment, so you're looking for elevation or depression. Um and they can happen together and if there is, if I spot ST segment elevation, you need to start looking for ST depression elsewhere because there more than likely will be. So I have an example on the next page. So yeah, so I'll show you that. Um But if you see ST elevation somewhere, look for ST depression elsewhere, OK? And then your T waves, so your height, so everybody knows about the T 10 to T waves for hyperkalaemia. So look out for them. Our T wa inversion could be like a sign of an ante or some kind of ischemia. Um And then summarize. So for example, like this is CG of such and such taking on blah blah, blah. Um The rate is the rhythm is and it is. I see like, OK. Um that's where your diagnosis. OK. So this is an example. So I'm going to give you a wee second to go through this to your rate, rhythm your whole thing like that. And then on the next page I'll, you know, give like what answers I had for it. OK? Um So we'll just give you a few seconds to do that. All right. So someone said, can't you normally see AQ wave? Um, so the pathological ones are like deeper and a lot worse. Um, like, like if you look on this one, they're like quite the smaller ones, I'll try and look at, see if I can get a picture of a pathological one. OK. So that there is like a pathological oh, key wave. OK. So you see the way that the key wave start there is like very deep and wide. Um, that will be a sign that someone has had a previous m so you might get like a mini one and normal ECG. But if you're seeing like a big one like that there, um, that's normally not normal. Ok. Ok. So I'll go through this nine. Ok. So, um, I got the rate then to be 84. So what I did was I just, I sometimes just count them the way across it at 123456789, 1011 1213, 14, um 300 divided by 14, then is 84 BPM. The rhythm is regular because there's the same number squared between each R um wave and then the cardiac X is normal because one is positive, two is more positive and then three is overall negative um P waves that are present and each of them is followed by a QR S complex. Um Pr interval is three small squares. So it's normal. Um QR S complex, it's not widened and it doesn't particularly seem to be like very um tolerating and maybe a wee bit tall actually in this one, but it's not too bad. Um normal morphology, there's no like delta waves or any weird things like that. Um And then the obvious abnormality here is that this person is having a stemi. So I've circled it there in V two, but you can see it there in V one, V two, V three, V four and V five. So it's just ST eight segment elevation. And then joy, I said like if there's ST segment elevation, there's probably ST depression somewhere else. So if you go to um VF there, you'll see ST depression. Um And then also in two and three, there's ST depression there and that's just like reciprocal changes um grand and then the T waves are normal. So there's no inversion there that I can see from them except for a VR which is normal. Um And then. So yes, the diagnosis is anteroseptal stemming. So hopefully that. Ok. Ok. So then you start. So you should all be very familiar with this by now. And um I would recommend like stealing one of these like a not filled in one from ward and just being very, very, you know, familiar with it. And you're able to say, you know, the birth rate is 25 that's very high. They're scoring a three for this. The um BP is, you know, 81/70. That's very low. They're hypotensive, they're scoring a three for this. And then the end say what their overall new score is on the puppy septic. So say I'm really worried about this patient. I'm worried they have sepsis. I'm going to activate the sepsis six and then you can say what the sepsis six is OK? And then a fluid balance chart. So yes, stay one of these from Lord as well like a one. and this is the front of it and this is the back of it. Ok? So the front of it is filled in by the nurses and HC and stuff. Um But what you want to look at is the bottom, but it will tell you the intake and output and then they're balanced for over the 24 hours. So it'll tell you if they're overall losing fluid or retaining fluid. So that's particularly important for heart failure patients and stuff because they will try to hold on to fluid. Um, so you want to see if you need to restrict them anymore or give them free or anything? Ok. Um, and in the back that's where you'll do your prescribing. Ok. Um, there's a wee box here that tells you what all of the fluids have in them for electrolyte wise, that's what I to look at now. You're not going to have time to do that in Os. So you can look at it now, but in SCA you're not going to have time. Um And then also there's a box over here, which is very useful for if you're trying to work out, like if you want to give someone a liter over 12 hours, instead of having to work out the rate, it'll tell you in that little box. Um So it's very useful. Um So you don't have to work it out and then this is where you do your indications the date, the time, the volume infusion type additives, ra and prescribers signature. So just be comfortable with that because they could get you to prescribe it. OK. Um So this is what I filled out. So this is like if someone was like septic or something, which I think if they were going to get you to do a fluid and start to like prescribe fluids, I think it would be just a bolus for someone who's septic. So uh so you do your indications. So fluid bolus. This is A B on the ninth of the 5th 9 a.m. 500 mL, 0.9%. So, chloride, no additives, give it stat on your signature. OK? And then the nurse will fill in this other bit or whoever's, you know, hanging up the bag. All right. Um So that's the way you do that. So I would look over bolus and maintenance. I think it's a lot less likely that they would get you do replacement. Um They could but unlikely. So I would be very familiar with Bolus and then also quite familiar with maintenance. OK. Uh The osteo topic is also very good for it. I keep blending it very well. OK. So management. So yes, you'll in third year, it's more that you'll be asked this at the end of the station. So like what would you do next for this patient that you've just taken a history from or something, you know, um or, you know, if you're in like your interpretation station with a news chart and stuff like that and, you know, they're septic, they're going to be like to you, what are you going to do with this patient? Um So you won't be able to answer them questions. So always ask for protocols. Nearly everything has a protocol DTA has a protocol, hypoglycemia, hyperkalemia, like ask for the protocol and that just shows safe practice. Now, if they don't give it to you, that's grand at least you've asked for it, but they probably will. And it is safer, like, in real life, it is safer for you to stand there as a doctor with the protocol and do it right than to try and go off the top of your head and get it wrong. Ok. So start with the basics again, you know, your oxygen and things like that. Um, and then absolutely call your seniors if you're worried at all. Ok. So like if you have someone with hypoglycemia who's like passed out unconscious, do you know you can start giving them your fluid, you know, the sugar and stuff, but you're going to want your senior to come down and see that person because they're really unwell and that is a really sick patient and you should not be looking after them on your own as an F one. Ok, same like if someone's very septic that's, you're not going to look after them on your own as an F one, you'll start the whole like management of it and do your assessment of them. But like you need help. Um And then sometimes people get very mixed up with glucose and insulin in ay and it is because you're just sitting there in the panic and stuff. So if you're ever asked about what you're going to do with someone's insulin or anything like that, just take a wee second and think about it because people always get it wrong. Ok? So, and the way that I remember it is like if their sugars are low, then you give sugar. Ok? And if their sugars are high, then you want to flush out the sugar, right? That's the first thing with the sugar. And then if they, if they have low glucose, you want to lower their insulin. If they have high glucose, you want to higher their insulin. Ok. So if you're asked, what are you going to do with this person's next dose of insulin? You want to think about that? So if someone's just had a hypo, you're going to lower their insulin because they have a low glucose, you don't stop their insulin by the way because I just said hyperglycemia. But um low sugars, lower insulin, high glucose, higher insulin. OK. Um I have to just take a wee second before you say it because as I said, queen sometimes just takes your first answer. Um which is very frustrating. But OK, so the portal is very, very good and it has like the um algorithm for this. So if you just go on to that and then click that thing that I have in the red button and the red circle, it's brilliant. So be very familiar with that. It talks through it really, really well, um I have another question. Can we get ABCD emergency management of DK A? So when I was in third year, it was absolutely not, you will definitely not be getting ABCD E. Ok. Um And as far as I'm aware that is still the case and I've asked fourth years who would have been doing, who also did like the C 25. And they were also also think you will not get an ABCD E. Now, I'm not saying that 100%. Ok. But I don't think you will because that's 1/4 year thing and you haven't done the A&E yet. So I don't think Peanut Queens would get you to do that. Now, you can always say it at the end of the station, I would do ABCD on this person. But I really, really, really do not think they're going to get you to do any of that because first of all, you haven't even taught how to do airway or anything like that, you know. So I really, really, really do not think you'll get that because we definitely wouldn't have got it in third year and they haven't introduced any into third year. So, and the fourth years seem to be under that impression as well. That was continuing to be 1/4 year thing. Ok. But it could just be like, do you know they show you someone's or they tell you someone has been hypoglycemic, you know, talk through what you're going to do or someone comes down and d you can take a history from or something and then be like, so what are you going to do? Next, do you know? So it is not very detailed management in third year. It's just like, what would you do kind of thing? Ok. So yeah, so I take a very good off that protocol. Um In the next slide here, I have like the summary kind of thing of it. It's too big to fit on. I can fit it all on like a s um But basically you're giving them loads of fluids because you want to flush out that sugar. Um And then you're giving them insulin and you're given that 0.1 units per kilogram per hour and it's a fixed rate IV infusion of it. And then, so that's to reduce their sugars to move it into the cells and you're going to stop their short acting, but continue their long acting. Ok? Um So that's important to know and then potassium, you're monitoring that very, very closely. And unless their potassium is very high, you're going to give them this person a lot of potassium. And the reason for that is because insulin lowers potassium. Ok. So if you're giving this person buckets full of insulin, you're going to lower their potassium and you're going to make them very sick if you don't replace that potassium. So give them fluids, insulin, potassium. Ok? And you're treating the DK until the ketones are fixed, not the glucose. In fact, when the glucose is fixed and down to normal, you continue with the insulin and you start giving them sugar until their ketones are like zero. OK. So that's very important to remember as well. So I would definitely have a very good read over that document, but that's like the key tightens to know. OK. Right. And then hypoglycemia. So I just took this from the Queen's portal as well. So obviously there's like different levels of this. So there's, you know, bits where patients know they're hypoglycemic, They get a, a sore head, they're like, they check their blood sugars and it's like three and they know themselves, they can deal with that at home and that's fine or if they're in the hospital, they'll know. Oh, I just take like, do you know a bit of my or whatever? And that's grand? Ok? Or you can give the Gluco tabs and just keep an eye on them, check their blood sugars again. Um And then give them the long acting carbohydrate because if you give them the quick acting carbohydrate, um it'll fix it immediately but then it'll go back down to normal, down to low again. So just give them a long acting one like a bit of toast or something. Um unconscious and uncooperative. You're going to have to start doing stuff now. Ok? Um So that's when you give them the Gluco gel and just put it in under their lip. Um and then, or you can give them the Glucagon um a injection, ok? And then unconscious patient. That's when you're kind of starting to panic a bit. Right. And that should be ringing your seniors there. Um, even with the, you know, onco of patient, you'd be thinking about it. Um, and you're going to give them either the Glucagon or that, um, glucose. So I'd be asking for this protocol if they ever ask you about this in a nosy. Um, and just make sure you're repeating that blood and giving them the long they wake up and then if they've had a hypoglycemia, that's clearly a problem. They're getting too much insulin. So you want to look at their insulin chart and consider reducing future insulin doses, especially the one they've just had the same time tomorrow. Do you know? So if they've just got 10 units at 12 o'clock tomorrow, you might not want to give them the same 10 units at 12 o'clock again. Do you know you might want to reduce that down a bit um, to prevent that happening again? And you're going to contact the diabetes team as well because they're very good and they'll come and review them and tell you what to do, which is great. Um ok, and then we're nearly near the end here. So, yes, sepsis you should be very familiar with now. So you have high new score, do your sepsis. Six, take three, give three, call your senior and find the source. So it's normally either gonna be respiratory or urine. So you're getting your samples there. OK. That's what I'm gonna say in that and then hyperkalemia. Um so they've just updated the guidelines for this, I think it was this year. Um So this obviously isn't a very good photo but try and get this from the ward but make sure you're getting the new guidelines. OK? So I've put the wee pink arrows about what the new bit is. OK? So it's now 30 mils of 10% IV calcium gluconate and it's, now you give them Lala and that's to prevent the calcium from going high again. Ok. So I've done like a wee I've just written out sort of beside it there. Do you know what exactly you do? But you're giving them the calcium gluconate, that's just to protect the heart, it won't bring down the potassium, you check their capillary blood glucose. Um, because obviously if it's low, you know, you don't want to give them ap of insulin and then send them more hypoglycemic because now you have two emergencies on your hand. Um So you're giving them the insulin and the glucose together, um give them the salbutamol because that will also help reduce the potassium, check their capillary glucose and you keep checking it and then again, prevents it from going back up again and very tight monitoring in this person. Ok? Um This is also in the hyperkalemia kit. So this is how to give them the insulin and glucose, ok? So you drop the insulin and an insulin string, do your checks with your nurses, all that sort of crack. Then you put the stuff on the insulin string into the glass bottle of the glucose and then you take it out of the glucose bottle, the 50 mil syringe and into the patient. Ok. So you're giving them the mixed glucose and insulin together, right? Um and then this is just an example of like the monitoring. So they get their blood glucose done like every 15 minutes. Ok? So just be very, just be aware of that. Ok. Um And then, so yes, we're nearly here. So this is just the resources I use. So as I say, like a stop book is amazing. Um And so is the websites GKI medics website and their station bank. I would highly recommend that gig medical portal again has all them dos from 1st and 2nd year from like respiratory exam and cardiac exam updo exam. I'd be very familiar with them because that's the team they're going to use. Um Life in the fast lane is very good for ECG S. So I'll have a wee look at that and then again, like the wards, like speaking to examining patients, looking at ECG S ABG S, that's how you'll get familiar with it and comfortable with it and of course news, fluid balances, all that crack. Ok. So yes, the most important thing in your oy is to just try and stay calm because getting flustered is like it's very easily done, but it's very scary and you'll just start making silly mistakes. So, yes, just try and stay calm during them and it is going to be fine and it is, yours are very close to them now. You know. So you only have this to do and then you're free for the summer. So, um, just give it your best, go over the next few weeks, do the best you can and it will be ok. I know it's scary, but you will get through it. Um And then honestly, it's not as big of a jump from third year to fourth year, I think. Anyway. Um, so, you know, the hard part is, I think you behind you now. So good luck. Um, and thank you for listening to this. Um, I'm going to fire the wee feedback for into the chat. Um, and if you could fill that in, that would be great. And then you can get the, uh, what do you call it? You can get the sides from that as well. Ok. So, um, how would you recommend approaching revision? Do you do all counseling in one day and then all histories in another day or did you have a different method? Um, I don't know. We do, we took it by specialty, I think. Well, we did it this year anyway. So we did like, do you know, one day you know, we would meet up and like we booked the rooms in Mackay and stuff and um, we would say right today, we're going to do cardiac and rest. Um And then we would do, we would go through that. So someone would do like a history, someone else would, you know, do a co C and we moved around who was the student, who was the examiner, who was the patient. So we were all getting experience with that. Um And then we all learned from each other from that. Like if someone said like a good history thing, then we all learned. So I took it by specialty, did a history counseling, the examinations, all that thing for that specialty. Um And then, you know, you're like covering it all. Um But if you're like struggling more with a particular area, you might want to practice it more just depends on yourself. Um You had mentioned uh PCT at the start most likely being year four thing. What is PCT? Um I actually don't know when, when did I say that I'm with Avis at ABCD E delay at the start being a year four thing, I'm not sure. But yeah, I think it's just that the ABCD is more of a year forcing. OK, I will copy this link for you now. OK. And OK, so that should hopefully be in there and then I'll also um a QR code might be handier for you to um scan and do so, I'll fire it in here. But yes, so that is us finished with peers. Now, that's all the lectures. Um Normally I would give you my email address at the end, but I am actually away for the next, um, three weeks. So I'll probably not be able to answer. But, um, when I run back after that, you can, or you can put in like a message into the like whatsapp group and someone here to be able to answer it. Um, but yes, thank you very much and good luck with your.