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Hi, everyone. Thank you for joining. Um, we're gonna wait for a couple of minutes to let everyone who wants to join, I guess. Join. Mhm. Just logging on chrome so I can see the chat. What? Uh huh. Oh, yeah. It's only just half past, isn't it? Yeah. So we're gonna keep it running, I think. Let's give it two minutes. Yeah, a couple of minutes. And then start. Yeah. Do you wanna, I guess, get going early? Sure. Forgive me. I was swallowing a tablet, and I thought I was going to choke. I'll get off camera. Um, Hello, everybody. Welcome back. This is our fifth. No, that's wrong. It's a sex session. That's a typo. I'm changing it. Give us one second. It doesn't count if we restart the presentation. Ali, I can only blame myself. Yeah, so fast. I'm joking. Joking. Um, let me share our slides again. Weight? Not a strong No, not at all. As you can tell, clinical life has completely like taking our lives. Yeah, Okay. Trying again. Hello, everybody. Welcome back to this 123 s f. P series. We're into our sixth session, not our fifth clinical scenario session. too. So last week we commenced having a look at the common and testable clinical scenarios that you will likely come across in your SFP interviews as part of the clinical station. And we're going to be going through some more scenarios tonight because there's quite a few that that it's worth being familiar with. This isn't exhaustive, but just a taste of how to approach them. Yeah, and I think nearer to the end during the Q and A. I would also like to um, ask you, Ali, how you would deal with, you know, an angry patient or two de escalate the situation as well just to pick your brain as an F tuna. Yeah, Um, yes. So just whenever we're talking about clinical advice, this disclaimer stuff is really important. So as always, the views that we espouse in tonight's presentation and in the series in general are personal views or the views of the person speaking and not the views of the N. H s or the trust that employers as doctors, Uh, and the management guidelines that we talk about are correct. As of the most recent addition of advanced life support, L s or I should say your local trust guidelines and we'll we'll talk more about that and why they might not be the same. But anything that we talk about tonight should not be used as a substitute for your medical training. And everyone should continue to work within their own current scope of practice. Anything we say tonight is not medical advice. It's for educational purposes only, and should be taken as such. So, do you want to introduce Alex? Yeah, unfortunately, Alex is currently on nights, which is why he can't join us. But he chipped in with the slides, as usual. Um, he's, you know, currently on Jen Surge. So his nights are rough. Um, and he wants to be a urologist like myself. Hi. Everyone again, We just run through this every time, just in case there are new people watching as that sometimes is. So I'm an f y two currently working in my neurology job, and I'm looking at either neurosurgery or interventional neuroradiology healthfully. The latter, um I'm aqua. I went to Lester and I got into the lex, um, scenery. And I'm currently at three. And like Alex, I want to be an academic urologists, and I'm currently also intense urge. But I'm on Upper GI I predominantly, and it's quite super, super, super specialized, which means the juniors don't get to do. They're really tough. It's so again, this is just a recap and some of the slides that show up in a minute. We'll be able to to whiz past because you've already seen them. But the point is, as I said, Uh, these two paired sessions are all about the clinical scenarios and with these just want to highlight you. All that videos on demand are available for all the sessions we went through and double checked after some of you highlighted that you couldn't see them. So there are on metal on demand, and they're also on my YouTube. You got full access to everything for free. Yep, and that's all he said. Um, we already went through this in the first session. But remember, um, with the clinical station, you often get 2 to 3 patients scenarios. If London or and other theories do that, or you'll get one big stem, and usually you need to prioritize and this is based on clinical priority. And, um, they can give you unwell patients, or they can give you an ethical dilemma or situation. And when it comes to prioritization, we go into debt on our first session. But just briefly, you know that they want safe and reliable juniors, and you need to think about what will kill the patient first, because that is what they want to see in the juniors. So in general, what they're looking for, and it's something that's quite easily like examine herbal like you can think about it. From the Examiner's perspective, what is easy for them to just tick, tick, tick. So the you know, the most common thing is a is a greater priority than because airway is going to kill you before breathing. And then circulation is going to kill you less fast than breathing, etcetera, etcetera. And also you need to take into consideration the new school, which may or may not become relevant later today, and clinical trends because a one off CRP might not be as useful as a trend of CRP, and when it comes to ethical situations, they won't have clinical priority. But, um, to really, really show off, you need to get through your clinical stuff so that they can give you a big factor. Check mark or checkmark to make sure that you are competent and safe, but also that you're going to be caring and compassionate because these are all GMC take boxes and why expanded on again last week. You need to get your beginning of it memorized because this will help you not only for your finals but also the SSB interview. Um, so just get this to the T. Because when I was preparing for my AFP interview, I felt so so confident when it came to my house keys because I already had this down and dusted. I had all of the protocols memorized and most importantly, I had this rehearsed. So the Examiner's were like she knows what she wants to do. She knows what she knows what to like. Talk about. But yeah, prioritize these patients based on clinical urgency. I acknowledge that there are multiple a mild patients. Therefore, I will first see if I have colleagues to help blahblahblah exactly on the slide, and then you need to think about the practicalities and the practicalities are often You will bleed your nurse colleague because they're the person who probably notified you because they're the ones that are by the bedside. And they know, um, obviously the patients better than you do. Uh, and they'll they'll be the ones sleeping you. And then as soon as you go and you're going to do your 80 primary assessment and then you go through the stuff that we'll talk about today, but yeah, keep on doing it. I think I did at least 40 or 50 mark interviews. I kept doing it again and again, and again and again. It was so annoying. Yeah, I'll be taking you guys through to the first scenario, and I want some interactivity, and I think really is also going to be manning the chat during this. So let's dive writing because I want some interaction. You are f Y one doctor, hopefully an academic. My one doctor working on a surgical ward. Mary is an 85 year old female admitted following an argument list for in a Care home. She's been eating less and has newly diagnosed dementia. You called urgently to see the patient. As Mary is now confused and less responsive, what do you think could be happening Can anybody give me some suggestions Just from looking at this stem. And remember, you need to give me a couple of differentials because that's what they're looking for as well, Because you can't be so now reminded. Especially when you're working clinically. Yeah. Any any more or cheeky? Hyper nice Ibrahim uti or infection? Are they all What we have anything else? Maybe because she's recently been diagnosed with dementia. What else can cause a patient to be a bit, you know? Yeah. Delivering. Exactly. Yeah, a stroke. And I Yeah, well done, Becky. And as a pro tip, when it comes to Yeah. Yeah, well done. Yeah, because when it comes to your different pills, um, system like if you break it down, you know, like the surgical sieve or something. Have a system in place or go organ by organ. Because if you go organ by organ, you can automatically, like, plaque out like, different things. Because looking at what Becky said, brain delirium boom. That's one. Definitely, uh, cardiac. Could be an M i medications. Obviously, like that's a bit, you know, different, but yeah. Always come up with a way to just rip out some differentials. So moving onto our 80 a, she's using her own airway. However, there is some snoring. I'm not sure that's necessarily worrying. Respirations 16 Hassan, 94% on room air. No increased work. Heart rate. Fine. Capillary refill also. Okay, No radial delay. BP is a bit low, but like you would see that in a little. You know, my grandma was probably gonna have something similar. Temperature is normal. There is something, perhaps, indeed even that might be a bit alarming. Abdomen and calves, soft nontender and GCS. The eyes are opening to pain. And unfortunately, she's making incomprehensible sounds. And she is flexing when it comes to the pain. Looking at this, looking at our 80 what is, I guess striking. Yeah, IBM. Okay. And what else is a bit worrying? Looking at scenario one, looking at 80. Give me a couple more points. Other than the bm Again not. That's not like, Trust me, Amanda, when you go to clinical practice, um, that's going to be like that's going to be okay. Yeah, exactly. Snoring and low GCS Exactly. Yeah. And well, she's not really responding, is she? Her eyes are only opening to pain not to voice. So not the best we've identified that. This is obviously, um, hypoglycemia, perhaps, and we've already talked about the primary concerns, and that's something that you need to audibly like announce to your Examiner. But when it comes to hypoglycemia, obviously we know that not much good by itself. What's the pregnancy? GCS Ali talking about his Niro obsession no matter what. Look, Ali, if I had the opportunity to talk about testicles, I would. But unfortunately, I can't. The only reason why I put it there is that, um, by my reckoning, it's eight, but obviously, But like you're going to intubate this lady. No, I I obviously it says, like the whole eight. Less than eight. Like you say that in, you know, textbook. But in reality you don't do that, especially if it's a reversible easy cause like this. You wouldn't jump to think about intubation, however, it would raise your alarm bells that this is not This is not right, but hypoglycemia. Obviously, we know that there are tons and tons of courses, and we already spoke to about we spoke about steroids. Addison's disease, potentially alcohol, will cause increased insulin secretion and I've actually never heard of beta cell hyperplasia. But when it came to, um, you know, making these slides, that's when it came up. But yeah, I always think about what can be causing it. Now, let's move on to risk factors for hypoglycemia. Can anybody give me some risk factors? Let's go for at least two or three. Yeah. Yeah. Well done. All diabetics, right? Yeah, I can give you that. How would you say that in a more medical way, Amanda? Yes. Lack of appetite. Fine. But then, yeah, adrenal insufficiency. Malnutrition? Yeah, malnutrition and all. Starvation, right. Like if your body goes into starvation, that's when you can have hypoglycemia. Yeah, well done. So, in terms of risk factors, we already went through. The insulin dependent people are diabetics. If they previously had hypoglycemia. If you previously have any episode of anything like that, it will unfortunately make you more likely to have another alcoholics never, ever forget. And I think listening to all these stories about patients it seems like a lot of alcoholics come through the door, especially through assessments and hypoglycemia needs to be on one of your top priorities, Especially if lowering GCS increased exercise because you're obviously using up all of your fuels. Right? And we already spoke about malabsorption and the starvation and with our patients also dementia. So talking about hypoglycemia, necessarily the glucose levels don't always correlate to how badly the patient is affected. And this is some more pathology pathophysiology about it and not necessarily useful for you right now. But the reason why it's important is because obviously, the lower the glucose level gets, the worse you become. And we do not want our patient to get to the severe point of a coma or, you know, them getting seizures. Right now, our patient is confused and they are displaying some weakness. So we know we need to get on it ASAP. Basically like we might not necessarily have to call our Med Ridge, especially with this when we we've caught it. We've done the B. M. We know what it is. However, that brings me to my next question. Does anybody want to know or tell me what the guidelines or treatment is for hypoglycemia? And anyway, uh, I guess, um, categorizing it. Yeah. Well done. Yeah, exactly. So that's one. Anything else? Yeah. Yeah, Okay. Good. Yeah, Exactly. Yeah. So we're using the of poo or a poo. I think they snuck in a see now with your silly mural people. Ali and Gross. Yeah. Okay. So can anybody list the drugs that we use for hypoglycemia? So we've got glucose. Anything else that we can use? IV glucose. We've already mentioned that. What are the other tools that we use? Yeah, I am gone. Yeah. Yeah, Exactly. That's pretty much going on. So I always say you would follow local guidelines, blah blah, because, unfortunately, it is. It can be dependent on just by trust because, like, for example, some trust may have orange juice. Some trust may give you Google Some trust might have, like, lemon juice that is enriched with some sugar or something like that. You need to just be careful and just say that, um and then obviously not so much for your interview, but when it comes to, perhaps you're asking because if you're at a medical school that you rotate between different hospitals, they may differ. So just just say that to be safe. Less than three in hospitalized patients and less than four. If they're symptomatic boom. Just treat them if they're hovering. If you're looking at, if you're looking at them and they have and they display the symptoms that we saw before, treat them so split as you guys rightfully said based on consciousness or if they're unconscious, if they're conscious, clearly, just shove them with some glucose look again. Orange juice, anything. I have had tons and tons of hypos, especially especially during my elective where I remember I was about to fall on to a patient and I lied to my consultant and I told them I need to go to the bathroom and I like like I described. And as soon as I left the theater whole, I just collapsed on the floor. Luckily, Anesthetist was walking by and like, looked at me and I was like, Are you okay? And I was like, Can I just have a biscuit? Just I need a biscuit and boom, I was back up again. So, you know, just I think I was conscious clearly because I was asking for help. But yeah, oral glucose. Then repeat whatever the blood glucose is just to check. And if it still hasn't risen, just keep on repeating it, especially if they're conscious. You can generally just give it to them. And when the patient is alert like hopefully I was, um she kept on telling me to go downstairs and have a proper lunch, because, unfortunately, a patient's testicles not as important as my own wellbeing. If the unconscious remember IV, you guys rightfully said IV glucose. If IV access can't be established, provide them with I am or sub cup glucagon. That should be all okay, but there are some pointers that this may be more relevant for your rather than your interview, because this might be obviously tough, um, to pick out in that setting when you only have 10 minutes to talk about a patient. But for your skis, remember, if you're making a patient go near by mouth without an appropriate plan, they might fall into hypoglycemia. If you haven't thought about them, what can happen? What can happen to them after the night or after the operation? What, then, if you've got the insulin units wrong, that they can fall into hypoglycemia again. But again, your pharmacist should have your back when it comes to really clinical practice, and unfortunately, nowadays because we're becoming more and more health conscious. There's also sugar free juice is which clearly won't help us in this scenario. But yeah, that is basically hypoglycemia. In a nutshell, I'd like to hand over to Alina for the second case. Hello. Um, thank you very much. I can't remember what the second cases I'll be working working along with you as we go through. So in the second scenario, I'm going to try and just speed things up a little. So we've got three cases to get through in just over half an hour. So you're an F one doctor working in the medical admissions unit. And may you, Sally, is 19 year old lady brought in following an unexplained seizure at home, which has now terminated. And you are called urgently to go and see Sally as she has now become vacant and they started to twitch in her bed. The movements have become more violent. So, uh, we'll give you the complete a TUI here. Uh, I don't think there's too much to it yet. So airway is her own. She's got a respirator of 16, sat to 92% on air with no additional sounds. Heart rate of 110. Normal cap refill. Know delay. Normal bp. Uh, everything else is pretty unexciting. And as you're going, one of the nurses reports that these movements have been going on for just over three minutes, by their estimation. So what do we think? What would anybody like to do with this young lady? Anything jumping out at you from the history? Um, any rapid intervention that you would like to make? Yeah. Amanda said, make sure that the patient is safe and the Airways open. Ibrahim has suggested another seizure. Not sure what the cause is, but we need to terminate it. Yeah. Yeah. Those two are really, really important things. And Thorne, Amanda said about making making sure the patient is safe. That is, uh, when it comes to seizures, and managing them is is basically 0.1 in your action plan before you do almost anything else. Um and that this case actually isn't very long because there's not a lot to say about it. The only issue is is basically the seizures are observations. Other than being a bit a little bit hypoxic and a bit tachycardic. There's not a lot going on. So if we move on to the next one, Yeah, exactly, Amanda. I mean, you you've kind of picked me to it there where it's fairly obvious what this case is about. But we're just going to talk a little bit about seizures and status epilepticus because that's the thing that you're worried about. So, um, I think it's always important, as we've said before, to to go back to basics, just as as I was just done with the hypoglycemia case. Everything is about the anatomy and physiology and the pathophysiology with doctors, and that's what we do. So the seizure is a sudden, uncontrolled burst of electrical activity in the brain. Most convulsive seizures last no more than 2 to 3 minutes, which self terminate. And that's a a feature of these seizures. Amanda has very correctly said, uh, status epilepticus There are There are slightly varying definitions, but you're right, Amanda, that five minutes is the point at which we start to get worried. Um, but what status epilepticus refers to basically, is this electrical seizure activity that fails or refuses to self terminate when it normally would, and when we've got someone seizing in front of us. It would be very difficult to tell apart whether this is due to discreet episodes of convulsion that are going on without recovery of consciousness in between or one single episode of continuous seizure activity. They would look, as I'm sure you can imagine, extremely similar, uh, without an EKG or something on them, we wouldn't be able to tell. So any convulsion that any convulsive seizure sorry that we see in front of us lasting five minutes or more without recovery in between episodes should be treated as status epilepticus because we don't know what's going on. So we assume it's continuous. Um, so oh, in fact, if it's if it's going to stay stable here, uh, what would anybody like to do In terms of managing this young lady's seizure? Amanda's already kind of said, Make the patient's safe and that that is absolutely correct. There's a few more things that we then need to do. So that's things like padded bed rails. If you have them blankets around them, removing any nearby objects that they might bash themselves on putting them in a semi prone position. Uh, for those, if you're not familiar with that term, It means basically the recovery position. So on their side, almost prone one leg under the other with their head down to prevent aspiration of vomit or any other secretion. Yeah, well done. Um, Ibrahim. So help from a colleague. Really? Good. And that that's a good point in general for these scenarios. I don't know what Aqua thinks, but I would argue that in these scenarios, it's never too soon to call for help. Um, like, there's no real penalty for doing so, Especially in the real world. Like you call for help as soon as you need help. Yeah, and if anything, people will flock to you anyway, if you're during the daytime in the night, Not so much. Yeah, it might be a bit slower, but they will come. Okay, if we just put the rest of these up, I'll just go through them quickly. So thank you. Um, Ibrahim had just said IV access will be important. Yeah. Yeah, very good. So someone has already said I think it was actually Amanda again said about securing the airway earlier, so that's really important as well. Um, with status and seizures, what we have to remember is while someone is fitting you do not go anywhere near their mouth. Do do not put a device, or especially your fingers anywhere near someone's mouth, because they will. Bye. Um, you know, you've seen, I'm sure, pictures of tongue biting and things during convulsive seizures. That's your finger. If it goes near the map. Goodbye to your exactly. Um, so in an inter ictal period when they're not actively seizing, that's when you get your airway. Um, if they're not stopping, you're going to be thinking about rapid sequence intubation, and that's that's very much not your job. So then we get to our drugs, and Ibrahim's very correctly, uh, said that we start with benzodiazepines, uh, such as lorazepam. So you start with a benzo, uh, again, this is one of those things we're checking. Trust guidelines is really important because different people have slightly different feelings about this. The one that I was reading was two doses 10 minutes apart. But those values will defer. So benzos such as low as, um yeah, mid as diet. As I think you know, there's buckle formulations. Whatever you can get into them, basically, is what you give a head onto in which is something like phenytoin as your second line. Uh, and then, if neither of those work you're into refractory status basically a resistant status and your then thinking about your third line drugs, ketamine, barbiturates, keppra. So that's things like phenobarbital and levetiracetam, which is keppra and all of these anti convulsive agents. Basically again, these are very much Med Ridge senior level like not our decision whatsoever. Yeah, and that's why 0.4 is help because if especially by that point, if someone's in status, But by the time they get into status, I t. You should already know about them because again, rapid sequence intubation I t u um, so I would say as soon as you realize someone is in status if you have not already called for help by that point, you're calling for Al. And then, um, someone said earlier that we don't know the cause at this point because it's very easy to get kind of whipped up with epilepsy and epileptic seizures as we are right now, you'll notice that I've given you basically know description of what the seizure actually looks like. We have no idea what is causing the seizure, So we need to be thinking about electrolyte imbalances. Um, I've seen enough seizures caused by hyponatremia. To be very aware of that, hypoglycemia again can cause seizures. As I said last time and think about things like delirium tremens as well. And with drawing alcoholics, there are lots of causes. If people are encephalopathic, um, there's there's kind of so many things, so stabilize them and then just before we move on to case number three seizures, especially when when you're a new F one, you called to deal with them. They look really scary. Um, again, I don't know how Aqua feels, but I think when you're not used to dealing with emergency seizures look scarier than other kinds of emergency because there's so much activity. Um, but that's okay. You know, they look scary for a reason. And actually, the protocol for managing seizures is really simple. You give them drugs until they stop seizing, or they go to I t u um, the nursing team, especially if you work in an environment like E. D. Or an assessment unit, or especially in urology ward. The nurses deal with this all the time they will hold your hand through it. And again, I think, Ibrahim said, before IV access for rescue medication, which, if you, if you've got even the slightest with that someone has seized before or you think they might get your cannula in in advance and get it bandaged down, um, so that you don't lose it when they become it'll. And then you can get your lorazepam in, Um, and maybe just even having a team discussion about it before saying, We know this person that says before there are high risk of doing it again. Cannula now meds prescribed and ready. And then it's much easier to deal with. I think that's the end of case, too. Yeah, and I think when it comes to scenario three, whilst it may seem easy, we've thrown in some ethical dilemma. So this is going to be a joint discussion between me and Ali and yourself where I would like both of us do it because finally, enough. Unfortunately, Ali, I think you've seen more of this patient population than I have. I'm from sorry, and most of my patient population is very, very white, so this is quite interesting, guys, Yeah, So this one lots of details have changed, but this is a real case that happened to me as an F one as a as a pretty green f one. Um, it's one that's really stuck with me, actually. Which is why I think it's quite interesting so that actually that and when I'm inviting. Yeah, of course. So you're an F one doctor working in E. D. Abdullah is a 37 year old man from Bangladesh who's returned from a trip abroad several days ago. He doesn't speak English, and your colleague is organizing a translator. You noticed that Abdullah looks extremely unwell and is sweating, so you need to go review him quickly. Let's quickly go through. And 80. A airway is maintaining his own no signs of distress. Respirations 24 SATs, 91%. No additional sounds, though. You see that his heart rate he's slightly tacky. Cap refill is fine, but his BP has dropped. Looking at temperature, it's clearly up his BM is down, and unfortunately, he's got some abdominal tenderness and bruising both flanks, though his calves are okay. Oh golly, I think that's from the previous case we ignore that. That's the type that that's his normal movements have been going on for three months. Yeah, but he's fine, but it's more. 80 is exactly what's happening. Ignoring the line above this question. What do you think is going on? What is striking to you already? Give me at least five points. This is one where participation guys would be really good. Because this is really a medicine like this is what happened. And we cannot stress that you will see this all the time. Yeah. Okay, so sepsis, shock, temperature tachycardia, tachypnea distress, hyper hypertension. Yeah. What else? What else can we see? Yeah. Bruising. Okay. Yeah. What else? What else is not normal? Yes. Splenic rupture. Kidney low. So that's tender abdominal. Yeah, exactly. Like you can tell. Internally, you can tell that this patient is not is not well right. Clearly, Probably more complicated than the first two scenarios. However, the good thing about all these scenarios for from today and our previous session is that they're very protocol ized, which may, which means that they are very, very examine. Herbal. Yeah. Anxiety. Yeah, Exactly. And the worst thing is, we might not even be able to talk to him. That complicates things so much more. That's all. He could talk to him. I'm from Bangladesh, so I can You can see exactly, man. Yeah. So moving on you guys, bang on before we continue. Let's talk about these different points. Ali, what would you do if you can't really gain consent from this patient because of the of the language barrier? What would you do? So the first thing you should do in any scenario where you don't know what to do is ask for senior help and that that basically is going to be the basis of everything that you do here. And I say this this is really this happened. So you've got someone who is pretty unwell based on everything. We've all agreed that they run well, if they are, we are unable to talk to them. Therefore, we cannot kind of relay anything important about the clinical situation, about how and well we are about the things we're going to do. Um, my position would be and again I'll ask her what she thinks, but my position would be there for that. You essentially have to proceed in best interests. You have an ethical duty to help someone who is unwell. Um, and they may be too unwell to even have, Even if they were able to speak English, then you may not be able to have much of a conversation with them if they're an extremist. Um, so this is a situation where I would argue, and this is ultimately what we did. The risk to life and limb is is greater than not doing, you know, you know, it is not doing anything is worse than doing something. Even in a In a not perfect scenario, Yeah. So you've already listed some key buzz words that we need to say in our interviews and exams. Um, best interest, regardless of the, you know, language barrier. You need to get on this because you've identified that this is an urgent clinical priority. But, you know, right from the get go, you need to gain some senior advice again. You will get brownie points for saying that. And why not see if there's no He is organizing a translator, but And whilst it's not the ideal situation, you can see if there's anyone that speaks the language that he does around either you're nursing staff or a dietician pharmacist, anyone who can make out a couple of words, just tell him that he's okay. And they were treating him even. That's better, because that can give the patient some psychological boost as well. But then obviously, moving on to the next point. How sick do you think he is? And this is to the audience. Is there any type of scoring system that we may use to help us determine how sick he is? Okay, Amanda, I get Q so far as the thing, okay? And you look so good when you say that. But all the nursing staff right are going to be using what money she has said, Mama. See, I'm not sure how you pronounce your name. Like I'm going to go with the pharmacy, but yeah, all of the nursing stuff and all of our performance are still, I think, based on news, Right. So we need to say that. And when I was talking about trends, we need to look at the news trends. So hang on. Yeah. So if you remember his observations from earlier, what do you think he'd be scoring? Not like Don't give me a precise number. But would he be generally scoring high? Low? What do you think exactly for him? Through the roof, Like my man is? Abdullah is sick. Exactly. Yeah, he's very septic. Yes. And now, Ali, I'd like to bring it back to you concerning conditions. What did this look like for you? Exactly more than four months? Yeah. Yeah. And it just for reference on on quick sofa, which Amanda has mentioned. If anyone is not familiar with what quick sofa is and what it's for, it's for calculating the risk of inpatient mortality for patients with sepsis. So it doesn't diagnose sepsis. It's to do with mortality. And this guy, I can't remember what the third point is. But just from his respiratory being 22 his BP being below 100 systolic, he's going to be high risk on cue sofa because you only need two of the three things to be high risk. But it's a good, quick scoring system. Um, sorry. The question is about concerning medical conditions. So what we have here, uh, I used to work on an HPV unit, and you have someone with all the hallmark features of sepsis. They're shocked. The tachycardic, the technique, the febrile. Um, this person also has, uh, funk bruising. Now, I don't know how how kind of clued upon abdominal examinations and things people are, but something that you will often spot is this, uh, flank bruising, which is a name. It has a name. Sign that flank bruising. There's also another one that's central and the named after two different people. Uh, does anybody know the name of that flank bruising sign? If you're looking for it in your abdominal exam? Yeah. So that's that's what this is. It's great. Earners sign. Um, which is the pancreas? Not Collins. Amanda. Very close to Collins, But not quite Collinson. Yeah, well done. Yeah, I always think about Yeah, The vampire. Always. Yeah. And this is so what it is retroperitoneal bleeding secondary to pancreatitis and pancreatitis is really hard because anyone with pancreatitis looks like the septic all the time. Like it? You know, you've you've got to, um, kind of manage the sepsis, but they may just have pancreatitis, but anyway, let's, uh let's go on to actually thinking about sepsis, which is on the next slide, but do you want to go through this? Okay, um, so I I think there is a lot of value in knowing this system. I don't know how other people feel, but this is the language of places like I t U. And if you're going to use these terms, basically you need to know what they mean specifically. So we we start with seizures, which is systemic inflammatory response syndrome not specific for infection, but just basically signs that something is a bit wrong that there's an inflammatory response to be taking the febrile or hypothermic, tachycardic or shocked. So looking for an elevated heart rate high or a low temperature technique as well as the leucocytosis or equally at Leukopenia. Especially if you you're looking out for things like neutropenic sepsis as well. That would be a big red flag. So then, to get from Sears to sepsis, you need a known or suspected infection. So this is one of those things where you're thinking. Could it be sepsis? Well, it could be, but without a good reason to think this person has an infection there. Know, by definition, it's not sepsis. Um, severe sepsis is then your diagnosed sepsis. which is seizures plus the infection with additional evidence of end organ dysfunction. Um, then septic shock is refractory hypertension with sepsis. We've used the word refractory twice tonight, both here and with status. Epilepticus refractory means it doesn't respond to treatment. And we actually talked about it in our anaphylaxis. Uh, talked last time. Um, so refractory hypertension, hypertension, despite continued fluid bolus is there BP is not coming up. And so septic shock is bad. And then this last one that I think we often miss off the end multiple organ dysfunction syndrome on mods, which is essentially the same as severe sepsis with your end organ dysfunction. But it's evidence of two or more organs in failure. So it's it's kind of if this is happening outside I t u. Then they should be in I t u Um, so that's the table to know. Yeah, and I think mods I You're very correct. I think I think we forget about it after severe and septic shock. I don't think we really appreciate the involvement that I t you need when it comes to Morgan support. But, you know, when it comes to treatment, can anybody tell me how we treat it. Finals and trust me. You'll be doing this every single day. Especially if you're, like, on your emergency assessment unit or assessments. One of those type of rotations already, for example. It seems like you have that, like, ready and loaded. Yeah. Broad spectrum, antibiotics, fluids Phototherapy. Fine. Yes, you did, didn't you? Don't even lie. Yeah. Okay. What else? Some Only some places don't use. Taz, Some some places use meropenem. I just refuse to eat. Um, Ali. Sweet. Um, this person seems terazosin deficient. Load them up. You know, Sylvester, apparently there you need to give I to your heads up. Especially if you know exactly if they're requiring organ support, you need to let them know. Yeah, and there is another team that we can also let know that will be absolutely essential here. Does anybody know the name of that team? They're kind of like an interim between us and I t u. Yeah, exactly. Yeah. Critically ill reaching 100%. They'll do that. They'll do everything for us, and they can really dictate and let us know. Do we need I t o r? They can really help us, but again, very important for us to say during our ski and also an interview, especially when it comes to a septic patient, because the patient that they give you may not obviously go into moods, but they can certainly drift into, like the septic shock or the severe sepsis picture. And, yeah, Amanda got the rest cultures output and relaxing. So I remember as three out and three in Yes, when it comes to urine output doesn't necessarily to be catheter, but probably needs a good a good eye. And you're nursing staff to tell you an accurate measurement. And when it comes to lactate, you don't necessarily need to get an ABG all the time. You can also get it from a VBG especially, for example, if the sepsis is probably not from your chest and most likely an abdomen. You cannot for a VBG. At least I know I've done some to get the lactate, and you do not understand how reassured I am when I get elected. That's like less than one. I'm like, yes, don't need to deal with it. Yeah, and then, um, three and obviously oxygen fluids, antibiotics. When it comes to oxygen. What should we give? A very, you know, an acutely unwell patient. What do you have to say? Naturally, that needs to come to you. Yeah, there's a really specific trigger phrase you need to say it is correct for your interview is correct for of skis. It's It's not exactly, but probably not all the time in real life, because he called Probably like it's not really that and again. But every other setting it is. Does anybody want to tell us the magic words? So boom. One more What there's there's no you know, there are two more words, and one, the first word is, is the opposite of low, and the second word starts with F. Yeah, yes, exactly. So 15 liter high flow oxygen delivered via non rebreather mask boom. That's what you say, even when it comes to a COPD patient. It doesn't matter because you need to fix the deterioration before anything else. Okay, so that yeah, sepsis is bread and butter medicine. It's it's probably in terms of medical emergencies. It probably is the most common thing that you'll manage as an F one. Um, now just a brief 62nd window to talk about the done in Kruger effect and the dangers of confidence here. Everything that is in the sepsis. Six bundle You are more than capable of doing as an F one, like on your first day of F one. It's the thing that you'll know back to front because it's the thing that we're taught more than anything else because it's one of the biggest causes of mortality. Um, just follow the protocol. You don't have to do anything weird and wonderful. However, this is something that I would equally advise as you as you go into practice and as you become, if one's always make your seniors aware that one of your patients is septic, do not think this is fine. I can do this myself as a hotshot F one because sepsis is still extremely dangerous and people can decompensate even if you've seen them and you think they look quite well. It doesn't take much to knock these people off, so never become complacent. Make sure you do everything quickly and make sure that senior is involved. That has more clinical experience than you do, because as a newly minted F one, and you know myself as an S H O. Now, the thing that we have to remember is we are the most junior members of the team and have not dialed in our clinical I yet that you normally build over the course of a career. Our seniors have that more than we do. So it's about knowing your own limites and recognizing what you don't know and what you don't have the ability to see. It doesn't make you a worse F one because you ask for help. Um, for now, whistlestop tour for scenario four. And then I want to talk to you guys about, um, what more talk to Ali and have a chance for Q and A as well, but really want to test you when it comes to, um, ethics as well. I'm going to have my brain pulled. Um, okay, so just with everything that's going on, guys, we might run over by 15 to 20. I hope that's okay. It is difficult to predict how long these things are going to go. If anyone needs to go before the end, that's absolutely okay. Everything's on demand and you can contact us anyway. But for the last scenario. You're an F two doctor working on orthopedics, uh, one of the ladies on the world. Margaret had a hip replacement yesterday. She's become more short of breath and is having some mild chest pain. So, yeah, here's everything that we've got. So her airway is fine. She's taking the IQ with SATs of 88% on room air. No additional breath sounds. She's tachacardic. Capri feels fine, though. And the BP is okay. Her temperature is fine. Glucose is fine. Pupils equal and reactive, Abdomen soft. However, a right calf is a bit swollen and tender to palpation in, and we get any C g. And she's Sinus tacky. Um, so, yeah, just really quickly. What? What? What do you think might be going on? And don't just give one diagnosis here if you can. If you can. I'd like two or three. There will be one that you think it is, but it's as important to be able to tell me what you think. It's not as what you think it is, as is much of the game in medicine. And for a word of warning, I guess, um, there was a patient that we had who had, uh, a chest like operation. Basically, it involves the diet, like diaphragmatic hernia. So when this patient was complaining of chest pain, the first Reg thought it was just related to her surgery. Another Reg. Then later in the day, they thought that it was possibly, like a pneumothorax. And funny enough, they both kind of forgot that this particular disease could be a thing. Which is why it's so important. We need to stay cognizant off differentials. Yeah. DVT infection, sepsis pee, all from Avandia. Yeah, because this person actually hits are certain criteria, don't they? Even though they're a febrile, um, they're still scoring off the tachycardic techinique that that by itself is enough to get you thinking. Is the sepsis um, there clearly not super sick, But they need looked at, don't they? Um, cool. So, uh, Amanda, you've got there the the two kind of things that would jump off the page here are you, um, Which, uh, if we go to the next slide, please? Um, Yeah, exactly. So we're thinking about DVTs and pes here. This lady old lady, that's got a massive risk factor in the form of a recent major surgery and now being immobile. This is when it comes to pas. I think the thing that people it's the thing that everyone knows is important. But also everyone gets wrong. I think when you're learning it as a med student is what the well score is for. Um, the wall score is used to basically delineate your management. So we've got here on the right hand side, the Wells score. You go through this for each of your patients that you suspect may have a P, and this is the key thing with a well score of four or more. And the well score is based on signs and symptoms of P four or more. You get a CT pa. Um, like you don't mess around, get a chest X ray if you want, But CTP A um, if the Wells score is less than four, that is a score between zero and three. That's when you do your D dimer for the problem. As you all know with the diner is it is incredibly sensitive and incredibly non specific. Um, if I stubbed my toe, I'm sure it will elevate my d dimer. So this is why you do it that the point of the D dimer test is it's a negative predictor. You're trying to use it to rule out. It's if it's low. The probability of a pea is low. If it's high, it doesn't tell you anything. Um, really about what's going on? Uh, so you've done your well score decided whether or not you're going to do your D dimer. If there is going to be a delay of four hours or more in getting your next stage of investigation, whatever it is, start them on some anti coagulation. You can always stop it, Um, in the meantime, and again this happens. You don't always have access to the tests you need. Whether that is ultrasound or a CT Pa. If you're worried, give them 48 hours of anti coagulation. It will stop them getting worse. So as per the most recent national guidelines, the treatment for a confirmed pee on C T. P. A. Is a dose pack a direct acting oral anticoagulants such as apixaban or rivaroxaban. Um, this will depend slightly intrust guidelines because lots of places are still using the old national guidelines where they treated everything with low molecular weight heparin such as you're on oxy powder and your delta part. And, um, and I think, for cancer patients or where the pee is thought to be due to cancer, we would still treat them with low molecular weight heparin. But that's a therapeutic dose, not prophylactic dose. So you're talking, you know, closer to 10,000 units of tins, a party or whatever than 3000 and aftermath. If it was provoked, that is, there's an obvious risk factor for their pee their clock. Three months of treatment, at least with follow up an anti coagulation clinic. If there's if it's unprovoked, there's no clear reason as to why they have developed this spontaneous clot at least six months of cover, the idea being that you don't know what caused it. But it could happen again at some other random time in the future, so we cover them for longer. Yeah, and I think that draws it just to the final bit. And you kind of spoke about this. Yeah, you know, DVTs and PS, you see them a lot, Uh, and risk factors are the big thing. This is why it's it's all about risk mitigation have to think about which of your patients that you're looking after is at risk for developing a P E. Because that's when we should be stopping PS and DVTs. It's it's far better just to give somebody a bit of Clexane or something at night, or warfarin or whatever they want to be on instead of treating a massive pee. And massive P looks different because it results in hemodynamic compromise because you blocked one of the pulmonary arteries. Um, so that's when you'll get your full on syncope. Profound dyspenea. They'll be really struggling. I think it's characterized by an arterial drop of 40 millimeters of mercury, I think for a massive pee. Um, so it's a really significant hemodynamic compromise, and this is the last big thing, both for your exams and for the interview. The most common we see GI finding in pulmonary embolism is Sinus tachycardia. Not s one Q three T three, this sign of right heart strain on the C G, which is very rare and also not diagnostic for pee anyway. No, I don't even know why we taught it. To be honest, that's cool. Yeah, but before you guys go away. I want to know. Ask Ali. I'll give you two scenarios really, really quickly. Like quick fire. Rapid fire. Yeah. Is this a thought experiment? You know, it's generally like something that I think is quite important clinically. So you've got a patient who you've taken care of your the f Y one for gyn surge and an angry patients relative comes up to you and demands to speak to you. However, you are very, very busy. But this, unfortunately, has to take some sort of importance. What would you do? Say this is an interview and you have two minutes to come up with your perfect answer. Yeah, so? And I might take more than two minutes to handle this. But this is just to outline my thought process as I'm being asked it by an interviewer by Aqua here. So when I'm thinking about a situation like this, back to first principles, Okay, this is an unfamiliar scenario. So back to my training and first principles. What does my training say? My training says that the patient that the unwell patient and patient safety is the clinical priority. Full stop, non negotiable. That always comes at the top. So if my patient is you know, the patient I'm looking after is really unwell, then I'm not even stopping to talk to this angry person. I'm saying No, not now. I'm dealing with something. And, you know, even if that means being a bit rude, it doesn't matter because the person is in danger. I need to go and deal with that. If I've got the liberty of having a slightly less sick patient where I can actually take 10 15 seconds to speak, I might say something like, I'm really sorry I can't speak to you right now. I'm busy looking after an unwell patient. What I could either do. I've got a couple of things I could do. You say? Would you like to speak to one of my nursing colleagues if one of them is free? If they've been looking after your relative, then they're better equipped to talk to you than me any way, depending on what the question is, um, I might see if one of the other doctors is more free to come and speak to you. If you definitely want to see a doctor. Or I might say I'm happy to come back and speak to you. Once I finished sorting out this unwell patient and I think that all three of those are very reasonable. It depends on the particular situation. Um, but patient safety first, you can be polite but firm as well. You don't have to be rude to say I'm sorry. I know it's not ideal, but I'm busy. I need to go and deal with this. You can either speak to one of my colleagues, whether that is a doctor or a nurse or somebody else who would be suitable, or I'll come back and speak to you when I'm free. I can't tell you how long that will be, but if you wait around, I'll come back and speak to you. Yeah, and then once you have some more time, you need to make sure. And these are things that you need to mention in your interview, Um, that you want to familiarize yourself with the patient, so you're going to read the notes, especially if you haven't really seen them before, so that when you're giving the anger relative, you know, information it is the most up to date and most accurate and obviously you want to de escalate it because sometimes they're angry because they just they're just not put in the loop because I think most of our situations and problems come from communication. So deescalating not necessarily apologizing, But we can apologize for the scenario that they're in for sure. And I think the best thing that you can do is making sure that you know about the patient so that when you do talk to the relative, it's all you know, you're all fighting for the same cause. Clearly, it might not be your first priority, but once it is because it has to, especially in this interview setting, you're going to make sure that you know everything about that patient, because that is what that relative cares about. And then, I guess in the similar vein, Holly asking you again if I were Let's say you and me Yeah, okay. You're a patient, and this is a gum clinic. And you've recently been diagnosed with ST I right? Just because yeah, I, um annoying and broody. And I want to know exactly, um, what you been up to So I start harassing the doctors that are looking after you for information. How would you handle that situation? So this is a situation Where, Where? Which principal, Which ethical principle is in play? Yeah, so just so I understand. So it's the it's the family member or a relative of a patient. That is, that is asking questions of the doctor and wanting to to no information, right? Yeah. So? So this is fundamentally all about autonomy. Um, and confidentiality. And the the right too privileged information falls under the umbrella of autonomy. What? What? I was kind of getting out here. At least I assume what she's getting at is, um, that if I'm that patient, I have the exclusive rights to my information or data that corresponds to me. And I may not be comfortable discussing the details of that with anyone. That isn't me, even if it is a partner or a family member or somebody else. And this is the type of situation where as a doctor, And to be honest, it's good practice to do this with any consultation with a new patient for the first time, or somebody that you don't recognize is saying, Are you okay to discuss this with this person here? Or would you rather speak to me by yourself? And actually, I mean again, this is a practice thing, but it could come up in the interview if they give you the right stem. If you get a with that, something is not quite right that someone is being very overbearing or is refusing to leave a partner alone. That's a big red flag. If somebody is not stepping away, it may be worthwhile. Yeah, safeguarding and trying to intervene. Um, I mean, it's unfortunately the example of this, you see, is is, um, domestic abuse cases where where it's very difficult to separate the two people, and often often with the team. You have to have a discussion about how you're going to try and approach this, Um, or it might be things like if a parent is in with a child, or especially with with a child that's approaching like the Gillick age, where they're starting to develop more of their own capacity, you can again take the opportunity to say, Do you actually, you know, would you rather discuss this by yourself or approaching them when their parents or relative isn't there and saying How would you like us to handle this. Um, there are ways around it, but it requires a bit of situational awareness. Yeah, exactly. But so I think angry patient, autonomy, confidentiality. And then I would also like to emphasize, um, making sure that you know about your patients and also knowing and battling between clinical party. And I think one of the last things that you can be assessed on a new interview really is, um, if you make a mistake and that's where duty of candle comes into play. But I am just conscious of time because we have gone a bit over. I'm so sorry. Yeah, Duty of Canada is really important and have a read spirit of candor and duty of candor are two different things. Um, that you have to think about, um in terms of if you get a near miss, for example. Say, say, uh, aqua was my patient, and she was allergic to paracetamol, and I accidently prescribed as some paracetamol, but one of the nurses went to give it and realized that I was allergic to, um you can have a discussion with the team about whether you actually need to go and speak to the patient and say, Hey, I prescribed you some paracetamol But then we realized that you were allergic and didn't give it. I think most patients would be a bit weirded out by that. It probably doesn't, you know. Yeah, but it's more you taking the learning opportunity and putting things in place to make sure it happens again. Obviously something like a wrong site surgery or, I don't know and administered medicine that was either wrong or the wrong dose or that they were allergic to. Obviously, that's a That's a big a big deal. Um, seek senior advice. If anything like that happens, yeah. So safeguarding DTs candle spirit of Kendall confidentiality escalating. Um, two seniors. Um, what else do we go through? Um, safeguarding? Uh, I'm trying to think, what else? And angry patients That's pretty much all that you you can get when it comes to your clinical priority. And, um, when it comes to confidentiality, they will Also London likes to do this. They like to throw in a policeman, barrages in and demands to get some information. And then you need to respectfully be like Sorry. My, um I owe it to, um my patient. However, in the best interest of the of the public, I need to give this information. So it's all about you mentioning that to show that you understand the ethical principles that are involved. Really? Yeah. Cool. Yeah. No, that draws us, I guess. To an end. Sorry. We're going a bit over if you can. Please. Please, please give us some feedback. Oh, we only need one person, I think to watch. What was it done? Yeah, the video's on demand to be to be nominated for the Exceptional Educator Awards. Um, which would be really helpful. I hope you guys have been enjoying this. Yes. And before, obviously. Please do the feedback. But do we have any questions? Thank you for being so conversant tonight, guys. It really does make a big difference to these asynchronous sessions. Um, and we appreciate your time. Thanks. Shoutout to Amanda, Becky and Abrahim. I think you guys have been smashing. When should we expect interviews? Roughly? Um, lust That's how you pronounce your name. Um, which dictionaries? Yeah, it varies massively. Some of them last year were interviewing Jan Yeah, until literally the week before the deadline. Yeah. So I think it depends how on it the particular Dina is London sent out there? Invites Hasn't haven't anything now. Yes, it under seven has as well. Actually, I thought I think I saw that. Yes. Seven and seven. Cambridge and KSS. So K e s s I don't think kss They will be November. December, I think mostly December. Have you applied to three schools? Somehow I think he's asking on behalf of his mates. He has to be. Yeah, different. Uh, something smells know, obviously. Okay, s s and my sticks together. Now, Um, I'm pretty sure in November, December Cambridge. I remember you had your seven. When was your seven? My 71 was before my northern one, but I think the invites went out around the same time. But when was the interview? Oh, um, I want to say end of November. I can't remember. Unfortunately, it's been it's been two cycles now. So true mind. I remember like it was yesterday. Do you know when the invites roughly come out? Uh, seven. So apparently they've already started sevens out already, as is London. Yeah, London seven. I don't I'm not sure if, uh, actually one of my mates has already heard from kss and Wessex. So maybe they're like doing it. Drip drip? Yeah, it's important to highlight. Like, just like with medical school admissions. It's a fluid process. So the chain apart from London, which is it's just what it was all to 50 whatever it is. Yeah, but, you know, sometimes because it's usually just one person sat in an office sending out all of the invites so things can get missed or things may change. So I don't, You know, don't get disheartened if if it doesn't come all at once. Yeah. And Cambridge. I'm trying to remember they weren't January or December. I think they were late November, early December. I can't I don't think any of them are January. I think West Midlands is John seeing if my mm Okay, Amanda, have you heard back yet? Put you on the spot. I don't even know which theories you've applied to. It's okay, Abraham. Thank you so much for being so communicative and being a sneaky sneak by already having prefilled answers. Oh, are you next year, Amanda? Yeah, yeah, yeah, yeah. Freaking your So are you going to get just go London and get 2020. Go, Cambridge, Oxford, You're gonna You're gonna smash it. I'm seeing if I can find my interview invites for it was sent to your work. Email them. Oh, they were That's right. Which now are no longer exists. All mine was sent to my Lester one, which is yes, I know. Unfortunately, um, but it doesn't really matter to be honest, you know, clearly from their perspective, like the, you know, anxious. They want to. Yeah, And in terms of preparation and things, you can start prepping now. Yeah, I looked at my age 80 around when my interviews were like you mad man. I remember I was the very, very last interview slot for Northern AFP like the last slot of the last day. And they loved you, but it worked out, uh, where I ended up, it worked out whatever, but yes. No, guys, please. I know literally. Um but yeah, we'll work out some support for you guys as you as you go through. You know, the next couple of sessions are going to be kind of more holistic. I think looks at the actual interview process. Um but we'll we'll try and get some resources and things together to support you. Yeah, and like, I'm very, very keen on giving some of you some marks as well. Very happy to sit down. Um, when it comes closer to your interviews, I can't do like I remember. Like when it came to whitespace questions. Unfortunately, I did get bogged down because there were at least 20 to 30 that was submitted to me last minute. I'm surely is the same. But when it comes to marks, I'm sure I will. 100% and on heart, obliterate some of you. Okay, put them on to obliterate. Going to support. I want to support them, but I'm going to give them harsh, you know, constructive criticism if they need it. I'm 5 ft two. I'm not going to obliterate anyone. Come on. All right, guys. Let's, uh let's draw things to a close. Thanks so much for coming in as every week. It means it means a lot to us that you would come and spend your valuable Thursday night, uh, coming and talking with us about clinical scenarios. But this is life, you know, this is this is medicine. It speaks well to you guys as future doctors' that you're kind of willing to learn the craft and be better at what you do. It's a good place to start, you know. Thank you guys. Very, very much pleased to feed back and add it on social media. Take care, guys. Bye bye. No.