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Hello, everyone. Thank you for coming. Um, we're supposed to start at six, but I think we'll just give it a few minutes for anyone in writing a bit late. Everyone, thank you very much for coming, and I think we might as well begin. Um, so my name's Daniel. Some of you know me. Um, already. So I've done a few sessions for a sits in the past. Um, so today we're gonna be doing psychiatry. Um, so this is an event sports. You buy a sitz medical Siris and Cardiff Muslim medics. And essentially, in the run up to the card, if it's ski, we're gonna be doing several topics. Um, help people who are sitting there dyschezia just achieve the best mark that they can. Um, so hopefully there is, uh, you know, quite a few card of medical students here. Um, I want this session to be It's interactive. It's possible. So if you wouldn't mind just, you know, one reason off. Mike, some of you just engaging as much as possible just so we can get through it quite quickly. Um, you know, some of us are fasting today, so I hope everyone's far so doing well. I hope everyone is having a good holiday on. Um, so I think without further ado, we can begin. Okay, so? So for the card, it is keep. Basically, there are two types of psychiatry stations, and this is, according to Allen's later, Who's the Guy Who Basically Lied? Psychiatry and Cardiff. So he writes a stations, and according to him, there's basically it's either going to be an information gathering type of station or explanation station. So information gathering station essentially refers to the communication station, which is one of eight stations on Diskus Station where you get seven minutes to take a full history. That's the only station when you have those 47 minutes, the other ones, they're gonna be four minutes, I think, apart from the medication review, um, but I think this that station is most likely to be either psychiatry presentation or gynie presentation. To be honest, just because those are the two history is where, uh, you know there's there's a lot to go through, and so they will give you that time to go through it properly. Um, so you basically take the history, and then after that, you're asked to form a differential diagnosis. You know, you get your most likely diagnosis. You may be asked to give a risk assessment as well, and then you'll be asked instruments, um, data. And then, um you'll talk about your initial and ongoing management about patients. So I think, to be honest, just the most like the, ah way that you're gonna be tested or psychiatry in the ski. So, technically, you can be asked as well to, uh, explain like an illness or treatments for patients. And that would be a separate type of station. Um, and so you know what you could expect? There is explanation of a drug to a patient. So no common things. Such a Z antidepressants. For example, If a patient started on an SSRI, they might say, you know, explain this to a patient and you'd be expected to explain that, you know, in in patient friendly way, how it works, why the patients being on its side effects and so on and so forth. All goes that you know, towards the end. But, um uh, yeah, so that's the other type of station. So I think there has been some confusion in the past about whether they can, uh, ask on explanation. Station off. You know, I I looked at the official card. If guidance and this is the liver based on what it says so says you may be asked a rationalized explain diagnosis, Grandal procedure, you know, whatever. So basically, even though I think this is really unlikely, because in I think in the urine fives who sat there ask you this year there was no explanation station and likewise last year for US Year Force and the year fives. There was no explanation station, definitely nothing kind of psychiatry based anyway, um, so I think it is unlikely. But having said that, I would just, you know, prepare on the most common things. Just so it does come up, then, you know, court quartets. So these according to translator, the conditions which you can expect to come up realistically, I think you'll only be tested on one of these on bipap, the ones in bold which I think are the common conditions, which which would probably come up on these ones over here, Pen on these ones over here. I think it's good, so I don't know about them and just have a basic idea of how to manage. But definitely the ones I would be practicing again and again are the kind of depression, anxiety, psychosis and basically these ones in bulb. Um, so just before we get into some of the cases, I just want to run through the kind of principles of a psych history on on what I would encourage you, you know, in your approach to any of the stations. Always just have structure, because if you if you have a structure to go buy, it doesn't matter. You know, on the day you may be a bit flustered, the actor maybe kind of giving you kind of different things torno But if you just keep it to a structure than you won't miss the important things. And so that's why I'm gonna just talk about here. So to start off with just with the presenting complaint. So any kind of site cash it presenting complaint is really important. Just Tosto abl ish, you know, the duration onset progression. And if there's any triggers, So basically how long it's been happening for, is it getting better or worse than you know? Have they had some kind of recent traumatic event or something which is precipitated there, uh, symptoms. And then once you've done that, then you need to ask some symptoms, specific questions. And so that's what I'm going to be talking about. Well, with each of the cases that I go through is, you know, for each condition you need to ask questions relating to the symptoms of that condition so that you can make the diagnosis. And I think that's the that could be. The tricky thing with psychiatry is you need to have kind of memorized soon set of symptoms, speech conditions so that you can ask those cut more clothes questions. So that s so we go through each of those into, um and then so every patient you should basically screen for depression so you can ask these two questions. So during the house to seven being bothered by feeling down, depressed or hopeless on, then, you know, have you lost enjoyment activities. So basically what you're looking for, there is low mood and Antidonia. So those are the two core symptoms off, uh, depression. If those are positive, then you can take a more thorough depression history. Um, but these things. You can ask if of any patient, really. Especially like sleep energy, appetite's those ah, you know, goods to just establish the kind of level of the patients. And then you briefly screen for psychosis. So, you know, people ask it in different ways. But, you know, have you heard or see anything unusual or some people say, Like, have you seen anything which other people haven't seen? Um, and then mania is Well, so have you had any episodes where you had an elevated moods? Okay, Now, once you've done that, then at this point, I would do, ah, risk assessment. And so that's one thing I'm gonna just mention again and again today is the importance of doing a good risk assessments in the psychiatry station. Because if you don't do this, then that's something that they can potentially fell you on, um, on. You really need to know the patient's level of risk in order to inform the management. So essentially any patients who is posing a risk to themselves or risk to other people that's going to war on admission may be under the Mental Health Act, which also just talk about to the end. But, um, yeah, If you don't assess the risk, then then that's that's definitely gonna be quite concerning. So whatever, uh, no. The complaints that might might be a different way of asking It's But you need to perform a risk assessment. Um, and then just quickly, so past medical history, including cost psychiatric history, and that So you can ask that Just track it their own. Any drugs, they their compliance with their drugs. Um, And then you can ask, you know, if there's a family history on, then the social history as well. So the social history is also quite simple, since I think in in a psychiatrist a shin, um, you know, because someone could be having symptoms on a background alcohol abuse, for example, substance abuse. You know, the occupation may play a role, and then so much has has stress. They are on also a so far as's understanding their their families situations on one thing that I think are diff conduce well in the issues they can bacon, uh, give a scenario where someone has a child, for example on. But it could be a potential safeguarding issue, so you would be expected to catch on to that on then. Last thing is just ideas, concerns, expectations. So the key with this is just take, you know, be thorough with the presenting complaint of the key things I think are getting also a risk assessment. And then also just touching up on this on this social history. Because this is where important stuff could be. You know, family history, maybe even drug history. It may not be that important that aside station. Um okay. So less again with the cases. So does anyone want to volunteer to basically just have a girl with taking this history? So it's It's probably something that you, you know, you might practice before it was nothing to unexpected. So, um, is the bottom? Uh huh. Wants to volunteer? Raise your house. Hi. Yes, KB Yes, I can have her. You don't get like you. Great. Great. Okay, So you are the F one working in the emergency department. And short is a 29 year old male presenting after taking overdose. So if you could take a seven minute history and assess the patients risk and then we'll go from there. Yeah, let me know whenever you're ready? Yeah. Let's just take a few seconds just to think about what it could be and what you want to ask. Well, beginning. Okay. Hi, there. My name is and I'm child for, you know, one of the fourth year medical shoots can just confirm your full name in your age group. Yeah, My name is uh, sure. Heavens, and I'm 29 years old. Okay. Is that okay for collusion? Of course. You're all right. Love you to meet you. So sure. No. I understand About what's what. You in here today, but could you summarize, in your own words, a timeline of events? What brings you in here today? Yeah, Doctor basically had a had a bit of a nightmare. I've taken overdose, and Yeah, I'm really quite panicked about this. I'm so sorry to hear about that. Um, could you tell me, um, what happened? What? What do you take exactly? Yeah, Yeah, I just took a lot of paracetamol. I just took them. No. Okay, well, first of all, I just like to say thank you. Well, chatting to me, I can understand how much more distressing time it must be. Well, I just need to ask you a couple questions that we can make sure that we can give me the treatment. That's right. Does that sound okay? Yeah, that's fine. Okay, So before you took the parity, small could tell me about what's been going on your life or what made you make make that decision. Yeah. Yeah. I mean, I haven't been feeling very good for the past few weeks, To be honest, probably the past couple months. Actually, um, you know, my separated from my partner. I haven't been able to see my kid, and it's just being gay. Me really, really down. Um, So, yeah, just this past week has been really dreadful. And, um yeah, last night. I just It just got too much. And so I took. I took a bunch of policies, more tablets and just wanted to end it. Will with that. Yeah. Okay. Um, do you know how my first of all this is going to hear about? Do you know how many tablets exactly you took? Yeah. I can't see them. I think was about 30 30. Okay. And did you take them with anything? Yeah, I just down them with some vodka. Okay. all right. And did you take the pills all at once or over a couple of hours? It was all the ones. I just took them one by one. All the ones. Okay. All right, Andi. Sure. Did you panel doing this, or would you say it was a spur of the moment decision? It's like I said for the past week, it's been really bad. So I have been thinking about Sitz. Yeah. All right. Okay. So once, once you were taking the medications, where did you Where did you take the parents? Feasible. I was just in my flat. I, um I being buying them in the past week, and it's basically I lock myself in my in my room so my flat may be able to find me. Um, yeah, I just took them all. It won't go like I said, Okay. Had you This is my time, Like a bit of an old question to ask, but how do you written a note for something? Two. Oh, I hadn't hadn't read the note. Okay on Did you buy a the Parsi Tool where they already your house? I went to buy them, okay. Or it's and solve. Now, off to the event. How do you feel about it? Do you regret what happened, or do you still wish they would rather don't be around? Um, I don't I mean, I I'm feeling quite nordeste of the moment, so I mean, yeah, at the moment, I'm regretting it. Okay. Right. Just give us a couple of routine questions now that we ask everyone. Do you ever feel like your hearing voices that are out there? No. No, I haven't. Do you ever feel like you're seeing things that aren't there? No. Do you feel like anybody is stealing your faults? Oh, no, no, no. You ever feel like everybody is hearing your thoughts or putting thoughts in your head? No. Okay. Orange. Um, have you ever tried to take your own life before? No, not nothing before this. I never thought I said. And have you ever hurt hurt yourself before? Um, What do you mean? As in Have you intentionally tried Teo harm yourself by the by, you know, cutting or otherwise? Oh, no, nothing like that. Okay, on. Do have you ever seen a psychiatrist before? No. Okay. On any other medical conditions that you have ongoing. Um, no, I don't I don't have anything. I'm just asthmatic. Okay? All right. And are you allergic to anything? No. Do you take any, um, elicit drugs too? Um, I have smoked weed on occasion, but, uh, nothing else, all right? And you mentioned you have Children at home. Is that right? Um, no. Well, my wife, my partner, we just separated, so I don't have, um I don't know, live with them anymore. Okay, So who's at home with you? It's just made my flateman to you. Okay, um, again, this might sound like a cold question, baby. Ever thought about her to your flatmates tool? No. Okay. All right. Um, okay, I'm just a couple more general pressures now, How's your mood been recently? Of course. You mentioned how you felt, You know, in the past day. But before that over the past couple of weeks. How is your mood be? Um, it's being just really down. Like I said, just happened. Being able to do anything. Okay. And how is your c being? Um, my sleep is being really disturbed. Actually, I haven't been able to get to sleep. Yeah. And what about your appetite. Appetite haven't been eating. What? I think I lost weight, actually. Okay. On derms a concentration. Do you? Do you mind me asking, Actually, Do you study or do you work? Um, yeah, I work. Um, I just worked in an office job. And how's your concentration beyond work? Really cool people. Okay. Um, so should I really appreciate you talking to me and take time out? Um, is that do you have any questions for me? No. Okay. From just Ah, another question. This might sound a bit old, but, um, does anyone know you money at all? No. Okay. On. Has anyone threatened you in any way? No. No way. Just also description. Because sometimes people in your situation mites and fuel under threat like someone. No, that's okay. I understand. This way. Um, okay. Should be under their Yes. Okay, good. So So which do you like to summarize your findings and just give you a diagnosis? Can dressed. Assessment? Yeah. Today I took a history for all Mr. Shauna, 29 year old gentleman showing presented with another overdose of paracetamol, which he took with vodka. He took 30 tablets on in one go. It was not a staggered overdose. Then he mentions that he fuels, regress and has no intention on off committed suicide in the future on. But he made the attempt at home while his housemates was away and locked the door, but he had not, um you're not getting a suicide? No, Uh, he mentions that he was restarted The attempt to come secondary all most likely provoked by the separation partner who does not allow him to see his Children. He has no diagnosis. I Catterick conditions has a past medical history of asthma is not allergic to anything he's known to use kind of a bleed. It was kind of this elicit Lee on. He works as an office worker. So I would quantify this patient as being a low risk patient secondary to the fact that he presented with no psychotic symptoms on, um, presents no intent of recommitting suicide in the future. I forgot to ask the patient for further protective factors that would prevent him from committing suicide in the future. If I haven't tried, I would explore these factors. Protective factors for the patient. Well, sort of factors why they did. Maybe his Children may be his job. Things that would prevent him from taking a second life. Yeah. Um Okay. So, uh, here's some investigations. Um Well, actually all ask, you know. Say so. How are you interested? Inspiration. Um Okay, So, before doing any investigations, I'd like to take an 80 approaching consult seniors in terms off. I would also like to examine the patient. I'd like to do another document examination on in terms of bedside. Investigations are like a blood glucose urine dip, a drug specimen, urine in case the patient has taken anything else that he didn't tell me. Azelastine the c g In terms of blood tests, I would like a full blood count. Reason? Electrolytes, CRP, liver function, test, um, five function tests. Um, Onda paracetamol levels azelas a further top screen, but that would only be done if the drug specimen urine It was indicated off requiring a tox screen on he. I think that's what much. That's fine. That's fine. So here are some investigations, so just that answer. But that was for me. Now this is These are the liver function test for sure. Evan onto the patient's named. It's birth on the date of results were taken on compared to any previous results available on system. I could see that a lot is significantly raised. A swell A z s t is raised. Um um Oh. I also should have sent them crossing and I and our but no more bilirubin albumin on pro forma been are increased. This would be in keeping with a diagnosis of the Paris eat. More overdose demonstrated by the artist. Cellular injury on the raise. Liver enzymes. Okay. Again. Okay, so here is a chart. So huge concern for this. Um, so paracetamol level was eight hours off the ingestion. Waas nine cheap. Just relying 90. Okay, so, um, the patient is meets the threshold for treatment line. Therefore, the patient should be started on IV anesthetic or Sistine. Another thing like, Oh, yeah. It's a pity is eight hours post ingestion, so on dicey should be initiated of the patient. It'll note sort of treatment line. Okay, great. So you're the kind of mentions, but So So what's your initial an ongoing management. Okay. So initially a said up to conduct a full 80 assessment. Would you like me to expand? Um, no, you're just full 80 assessment on like to take, I would like to insert two large bore cannula into the anterior cubital fossa. I'd like to take a regular observations on the new school. I'd like to prescribe IV anesthetic Sistine, the dosage of which I would consulting nice guidelines and talks baseball on, but also regularly monitor the patients. Paracetamol levels on their liver function test to ensure that they're going down. Also like to consider prescribing IV fluids as well as the allergies are on. Actually, a medics, as the patient mentioned that they were in pain on the allergies are consult the pain bladder, too. Consider which, exactly which I don't see that you use, um, on. But once the patient is medically stable, I'd like Teo make a referral Teo for a psychiatric assessment. Also initially at this one, I should have mentioned I'd like to consult a senior for senior imports that it's a patient on going. The patient mentioned symptoms that were and keep it with the diagnosis of depression. So I like to make a referral to the patient's GP initially for a formal diagnosis of depression as well as consideration for starting an SSRI. Such a surgery was also like to safety, not the patient. Um, I'd like Teo offer advice and tell them about what to do. Should they feel suicidal again? Is what it's consideration for a community mental health team. Input as well is a crisis team input. I'd also like to taken MTT approach approach, including myself on the GP. And as I mentioned the community mental health team on, uh, offer lifestyle advice for the patient to prevent or slow down there kind of issues. Yeah. Okay, so you start the, uh, confusion and the patient becomes nauseous. You see this rash, But they can communicate with you, Probably. They have no shortness of breath and the chest is clear on auscultation. So what are you gonna do? Okay, so this person has had an acute allergic reaction to any fertile assisting, which is a common side effect of the medication. What I would do is I would slow down the infusion rate at a slower rate. Point was, the patient is still it was communicate with me so I would slow the include I wouldn't stop the infusion completely yards slow. It's down. Slow your break? Sure. Could you name What type of reactions is? I believe it's a non. It's a anaphylactic wheat reaction. Yeah, very good. Okay, that's great. Well, don't know. I think we could leave it. There s Oh, Did you feel that went okay? Yeah, I was okay. I forgot to ask how long ago he took the medication. Will see that impact treatment. If it was within our we could have given charcoal. So I should have asked about what we've got on. I've got to ask about protective factors. It just wasn't sure what time it was. A lot harder, right? No, that's that's fine. I want to see. I think you did very, very well. You took a very good history was very thorough. Uh, and you were very You always seem memorized. All of these kind of questions that I ask about with regards to risk assessment and screening for psychotic. The pressure in on that, some of those up like schizophrenia as well. So I thought that was really good. Um, stuff you could have just explored a little bit more is like the physical symptoms they're having. So I just mentioned that feeling nauseous, like you could have asked you in any pain. It's all just stuff like that. But obviously, this is, um you know, the psychiatric history. So that that's fine. That best room, a focus, Um, on. But then the only thing is, like s. Oh, well, come on. So kind of structure. Uh, how to take a suicide history. But on you did before. Very well. Duren on. Then after you, you asked her current. You know that question. If we let you go today, would you do it again? The US That's exactly what you need to ask. That's the well done for that, um, you could also just explore. Like, how exactly did they did they counted? A Any Did someone find them? Did they present themselves? So that can give you an idea of the level of risk? Um, so, honestly, I think that was a very good kind of example of how to take a suicide history. So well done. Um and then we said, We'll just make sure I said so. Yeah, basically, just before, During after. You need to say, um, you know, before you know what was happening to run up to the event and then during walk exactly happened. Where and when did they take multiple substances? So I was on, um, elicited this person took alcohol and prosecutable on. Then, you know, it was it's staggered over those. Did they? You know what? Exactly? It was their intention. So maybe you could just ask that explicitly. So did you Did you mean to end your life at that point? Although I think I did pretty much say that, So that's fine. Okay, so when we talk about suicide risks, they're doing a risk assessment. There is certain protective back doesn't soon risk factors. So you can look at these here, So this person are with, um uh I wouldn't necessarily say they're mild, you know, if they've bean having a sustained low mood over a couple of months now on. But they did kind of planned this they did. You know, they went out to buy those paracetamol on day. I also mentioned they locked themselves away so that basically there trying to avoid being found s. So I think with these kind of risk assessments always best to just lean on the more severe side because that's gonna it's basically a safety and ambulate you're not gonna do anything wrong by saying Okay. It's just kind of moderates, maybe mild mortar episode rather than just saying it's mild. Uh huh. If that sounds reasonable, um, so, uh, investigations were really good. You're very thorough. Uh um, you remember when I showed you just to make sure you do a coag a swell? Um, I think you mentioned everything else. Um, yeah, these investigations. So they basically show acute to participate either injury. This is a markedly raised a lot e. And we have a low albumin and raised pee perform in time so that in the case reduced, and that's a function of the liver, uh, secondary to, uh, you know, damage secondary out parties all over this, um, on the manager was also very good. Very thorough. You could have said even more than what's on this slide, but yeah, just you can consult talks basis. Well, that's quite key for any kind of overdose or toxicity. Situation on really is long. As you say, you're gonna use 80 approach. Um, you're going to give, uh, a nice off the best are cystine. Um then that. Then that's probably enough to pass, you know, ongoing management's you couldn't whilst in the hospital they will be assessed by the psychiatric pa on team. So they will come. They'll make a formal diagnosis if they are high risk and they may be admitted is in a psychiatric inpatient. Um, and then with the cost on going, then use the biopsychosocial approach, which is very key in every kind of management that we're going to discuss today. Um, on. Yeah, it's still you could make a suggestion that this sounds like depressive episode. So the management that would be SSRI xyz on, you know, given example of the medication, it's always good. So such a state of our probable surgery, um, on in addition to about the cognitive behavioral therapy that aimed they're, uh, kind of negative patterns. So it's always good if you can kind of just say CBT on just address what it would be been in reference to. Okay, So, uh, just for this second case now, um, I I won't have necessarily a volunteer, but if I just get some engagements on the chat, uh, do you want just come on quickly. The anaphylactoid part. Oh, sure. Yeah, yeah, yeah. You nailed that to be honest. Um, so So, yeah, when you infuse knack, then as you said, commonly, you can get this anaphylactic reaction, which is basically, like, non i g mediated raptured It can cause it's like a it's a Curiel rash. And some of these kind of, uh, symptoms have been nauseas. Well, so basically, when you infuse this drug, I think the patient has observed for a now our just to make sure they are not having this reaction. But the key thing is that you don't stop it because it's not like full blown anaphylaxis. Um, you just stop and then we start a slower rate, which he said correctly, Um, okay, perfect. Thank you, Brits. Um Okay, so for this next one, let's just I'll just kind of go through it. Um, it's, uh, here. Uh, so, yeah, if you just want to type on the shots is to the questions I'm asking. So his eyes. A 22 year old medical student, she's being feeling low mood for the past four weeks. She's having a hard time with her medical school Good Sam's, and she feels that she's losing enjoyment in hobbies, which is feels tired and lacking energy all the time. So just sticking with that kind of structure off the psych history I was talking about, What's the kind of essential information that you want to know? What? This point? Yeah. Yeah, exactly. So we need to do a risk assessment. So I'll tell you that she's had no boats of self home. She has a history of South harm, harm others, no intention harm others. And those suicidal ideation. Just a bit of the social history there. So she's non smoker. Doesn't do any alcohol or any drugs. Um, on then just to complete the history. So she has apartment with history of celiac disease? She doesn't take any regular medications. Um, yeah, for this, um, if I'm asking questions, then just use the chapped function just so we can all see it. So, uh, yeah, no, no. Irregular medications. She has a family history of depression on, but, uh, yeah, that's just repetition there. So, uh, this put patient is obviously having some low mood. So what do we think are the Are some differentials of low moment? Yeah. So? So the most obvious differential. I think that will come to mind this depression on that Some people who also men mentioning hyperthyroidism there, which is a very violent differential. Um, particularly is this patient has celiac disease, So maybe there's some kind of water immunity going on there. Um, So when we think about differentials and excuse the ideal way that we want a structure, it the examiner ask, you know what's the differentials? Then you can say there is different kind of categories of differential. So this psychological there, maybe cardiac, respiratory, etcetera, etcetera. Um, you don't have to list all of these literally. If you said one or two and then you could give a few other alternatives that that would be that would be enough. Um, yes, it's getting the main differential was important. So it's a depressive disorder, so you you can categorize it is mild, moderate or severe. So I mean, if I if I give you this information, would you be able to categorize mild, moderate or severe? Yeah. Yeah. So I would agree. I would say this is a mild episodes, so I think technically a mile would be around less than five of the kind of symptoms of the pressure. And so, um Yeah, you want a bit more info? But she's not having any sports of stuff harm. She's I didn't say it, but let's assume she's not having any psychotic symptoms. So that basically was out severe. Um, next story, so mild or moderate, I think you could support um, and then other kinds of French rolls you could mention. So there's something called acute stress disorder. Basically, if it's period of low mood following a particular event, then that could be. That could be something to mention if they've recently had a bereavement and you grief reaction could also have bipolar. They have a history of mania as well. So that's something he's asked them. Um, there's some other things, all of know in this case, but some things to think about if it's a psychotic depression or if they recently had a baby on gum. Uh huh, Yes, that that they could be having some some postnasal depression. Um, then other organic causes could be hyperthyroidism, with some of you mentioned could be the drug reactions. That's why it's important to look at them the medication history, you know, unlikely, but something to consider. Um, could be on intracranial pathology. They, um So what's type of investigations we want to do in someone presenting with the root? Yeah. So thyroid function tests was correct. Um, i'ma See, maybe, um, I think, routinely, I don't think it would be done, but can you think of any other? Uh oh, sure. Like a Oh, sorry. Yeah, I would just look so MSE. Yeah, you could do that. Um, any kind of screening tools which anyone can think off. Yeah. PHQ nine. Exactly. That's what I was thinking. So when we give investigations and the risky as I said, whiz, stick to a structure. So you know, different people have the other things, but I like to stick to bedside bloods or for this X rays. Other imaging, special test. So just going through that, So that the bedside, you could do a full physical examination. So I would say that, to be honest, that any patients, if you could be more specific. That's grades. But in this case, just think about the organic causes to rule out to a full physical examination. Um, blood. You'd want it to a full blood count. You really? Actually, I started function tests. So be prepared to justify to the Examiner why you're doing each of those things. So why in this case would be want to do a full blood counts? Yeah. So anemia could be causing tiredness to the, you know, mimicking some of those depressive symptoms. Similarly, you re and electrolytes some electrolyte abnormalities could be causing the symptoms on. As you already said, the thyroid function test important, right? Hypothyroidism. In this case, I don't believe there would be any kind of warfare tests if you had suspected some drug abuse. Then you could do you urine drug screen. Um, and then as far a special test I put under that those kind of question is that you could consider so PHQ nine is used. I think it's recommended by nine assists Screening tool for depression and it basically just ask some of those questions relating to the D S M criteria. Um, so if you take it a full history, to be honest, that there will be an overlap with the PHQ nine. But it's just something to say to the Examiner. Um, yeah, who? What's your organic causes? So how within a manager patient presenting so in the in the side station. You're always going to say I'm gonna use the biopsychosocial model in other stations. You can save conservative medical Surgical. Obviously, in this case is not gonna be any insurgent, Kel. Um, but there is an overlap. So I would say that the bio is gonna be the medical aspect on Do the Conservative is is more like the psychological interventions that you do. So, if anything, you could say, like, psycho bio social. But it doesn't really matter, because a lot of those things, the first line anyway. So for for a mild or moderate depression, first line is actually gonna be, um, psychological therapy first. So this was a recent change in the nice guidelines, I think where they're now No. Routinely recommending SSRI first lines of people with mild depression. So I should change us, actually. But I don't think any examiners gonna kind of have too much of an issue if you if you give this so SSRI would be first line. So or like I said, a second line after the therapy, so given example of medication, is always good citalopram socially. Um, it's important to know about the serious side effects of medications they were prescribing. So one thing that happened in younger individuals is an increased risk of suicide. So in GPS, what they do is they just they follow them up. I think one week or two weeks just to, um, ensure they get it on okay. And titrate the dose if necessary. Uh, based on my mood, um, if the patient so psychological intervention is key in the management of the pressure is so it's a quality of behavioral therapy. Um, aimed targeting the patient's negative for patterns Onda psychoeducation as well. So self help books online Resource is charity reason that kind of thing on when it comes to the social sides, Sometimes it can be a bit of a bit hard to kind of stretch it to that point. But there are things you can do, so, you know, sign posting to any relevance. Authorities. Patients having difficulties would say, say, if they're having some kind of substance abuse problem, then there is gonna be a relevance place to refer them to. So if they're having a problem with the employees moons, they require benefits than you can sign post into that way, or if there's any particular charities that can help them. Um, so if they have a severe depression, um, say the highest. It's like a post cysts or their suicidal. Then you'd want to do an urgent referral to the community mental health team and you'd consider hospital admission if there a risk to themselves others on further management options, you could just mention. But, you know, we're gonna be doing that That's gonna be initiated by by the specialist is going to be the U C T or antipsychotics. Uh, okay, so, um, case number three. So does anyone want to volunteer to do this to just practice this history? Well, do it more in abbreviated, abbreviated way, just for the sake of time. Does anyone volunteer? Teo, take this mystery. So what raised their hands and cake? Thank you. I hated the same. How good is this hard? Yeah, I heard. So, Yeah. Mary is a 43 year old female. She's presenting to the GP just being stressed all the time. So if you want to take, I said seven minutes. But if you just want to take a quick history on dust, give you some ideas, it's still you know what the differentials could be. So whenever you're ready, hurry. I am Mary Mining. Sure. You know where the full the medical students and that's confirmed your name in a judge? Yeah, I'm married on 42. Okay, um, what's what you're in today, Mary? Yeah, basically a doctor. I mean, if you it's really stressed. I recently, um, every day. I'm just worrying anything that any problem I have is just really stressing me out. Um, I don't know what to do. I'm really sorry to hear that. Sounds like you're going through quite a lot. How long has it been up in a pool? Um, I don't know. I've always been like them or stressed out type. Like I'm a warrior. But I'd say in the past 12 months, it's just gone. It just kind of going out control. Like, I don't feel like I control my thoughts anymore. Want to let you control your thoughts? Yeah. What do you mean by that? It's just that the worry just that's all I can think about sometimes. And you know, if I like it when I go home, it's okay, but the second I go out, I just It just gets a little too much for week. Okay, So you've had this overwhelming sense worry for the lost 12 months, Did you say? Yeah, And you say it's associated really with you leaving the house? Yeah. That's and just any kinds of stress that happens. Like, uh, I'm quite busy, Lady to the honest I have, you know, four kids, and it just gets off for me. Yeah, I can imagine. It's a sound like you go home for Quite a look in general. How's your mood been? Um, my moods been okay. Yeah. Okay on. Have you ever noticed any, you know, sudden attacks off having quite high anxiety? Yeah. I mean, I can do Sometimes I feel a little bit sick. Um, but the main thing is, I just feel really tensile over. Well, really tense. A little working. And you said it was so a month ago. Did anything happen around that sign? No, not particularly. No. Particularly. Okay. On in general, obviously you mentioned some changes to your thoughts. Have you noticed any, you know, Have you noticed anything that nobody else has seen or heard stuff the other people haven't heard? No. And He said you're having some some headaches. Um, nauseousness is well with that, right? Yeah, Yeah, I just I do get these headaches now and again. And I just built in my in my body, like in my shoulders and my stomach and my legs. It's a little just tensed up. Okay. Have you noticed any other symptoms? Such as a racing heart rate? Yeah. Yeah, I do. Get that. Well, well, parenting curry. Okay on. Have you noticed? You know, Germany. Intolerance the code? No, not particularly. Okay. Perfect on. In terms of other symptoms, you haven't. You said hi. Headaches. Haven't had any fevers or anything, have you? No. Okay, I have you noticed any pictures in your bowel habits? No. Okay, so the mountain, the main thing here is really your anxiety that you've been feeling. Is that right? Yeah, I guess you could call it that. Okay. Do you have any other middle conditions? It's a, um I just have asked me. Okay. You just have asthma. And have you had asthma for a while? Yeah. Yeah, I take a pump salbutamol, okay. And is controlled your asthma. I do have to use my pump a lot today. Unless, Okay. Is that because you have attacks or shortness of breath, too? Yeah. Okay. And how often does this happen? Um, like, every other day or so every other day. Okay. On has this. You know, this your feelings as it stopped you from living your normal day to day life. Uh, it's definitely affecting. I don't feel like I'm dead. I could do is much as I used to. Okay. Well, I'm really sorry to hear that, but thank you for speaking. Be sore for I just ask you a few more questions, and then hopefully that will be everything. Do you have any other medical conditions besides your ass more? Have you ever seen anyone for anything else? Um, no. Okay. And you mentioned you obviously take your cell, be your sub. Use more inhaler. Do you take any other medications? No, it's just that that one point you were gonna Jesus all No. No. And just a question. We ask everyone. Have you tried to meet a recreational drugs? It's all No, thank you. I'm Jeff. Any family history of any conditions? No home. Who do you live with? It's me and my four kids. Yeah, and how they are. They're okay. They're very rabbity. And they keep me busy. Um, the other Okay. On the oh, Jeff, many ways away. You know, relieving this tension is what you have. No, I just don't know what to do. Okay. Well, that is a good thing that you come in in terms of that on Just again. Something. We all see everyone. Do you smoke a little, uh, used it. Okay. On when did you stop, like, 10 years ago? Yeah. Okay. Ask you. Thank you. And then do you drink? It's a little No, thank you. Um, is anything else that you'd like to mention that I haven't asked about? Uh, no, that's a good okay. And besides, obviously this this tension you've been having for the last 12 months is anything else you're concerned about. Ah, no, no, that's fine. Okay. Well, thank you for speaking me today, Mary. I really appreciate your time. Oh, hopefully I'll get back to you soon with some a blessing. Keep you on how we can progress. Right? Okay. Well, the room. So, um, unless just quickly just world terrorist. So if you want to just quickly summarize what you think is going on and what you're born you're diagnosis is that it was 42 year old female with 12 months off Excessive oriole. More days and not we're somewhat anomic symptoms. I'd say these constitute generalized anxiety disorder. Okay, on dumb, any other differentials you'd like to think about so potentially a phobia that she did mention that you had a fear of going outside. Oh, so the phobia would be another one on another one would be, uh I had another one, but it's going off my brain, so that's okay. That's fine. Um, So how would you investigate the city? Um, so I would like taking more focus history What I would like to do, um, in to stay examination with her. Um, putting from this, I'd like to do some some basic observations. The EKG, her respirator. I mean, I'm following on. Take some bloods. Oh, my like to particularly check her thyroid function levels. Oh, you and the CRP is just for baseline. Um, and I'm sure that must be like some type of anxiety questionnaire out there that I'd like to use. Um, I think they're the main ones. I could think of right now beneath Burger. Anything else? I think. Okay. You were about to say something thing. I was going to be easy, but on that sounds reasonable. Um, okay. And how would you manage this lady? So, yes. So I wouldn't say she has generalized anxiety disorder. However, you gonna manage that? Um, if you have generalized anxiety disorder first, like you, um I think, like you said, we'll do a bio psychosocial approach. The first line being a TBT therapy. Oh, and if necessary, we could add an SS. All right. Okay. Sure. Eso she wrapped up there? Yes. Fine. Okay. Yeah, very well done. That was good. You got a lot of the symptoms that she's having. See, this is basically a case of, like, severe anxiety and probably 50 into, like, a generalized anxiety this morning. So you took a good history. What I like about it was that you did a good kind of systems review s. So I think you You obviously trying to rule out some kind of hyper thyroid situation, which was good. Um, the one thing with your history is I may have missed it, but did you did you ask about risk? You know, I didn't figure it's osk. Yeah, Yeah, exactly. So that's fine. So say say, if you did forget to ask and you just have a few minutes at the end of the station. Um, that's when you want to be thinking about that kind of so called like red flag things that maybe you missed. And then at that point, you could just say, Oh, you can't just say I'm sorry to the Examiner. You could just say I I just realized that forgot to ask about the risk. So I'd like to ask the patient if they're having any thoughts of self harm suicide ideation or harming others on. But that's the best. Better than nothing, basically on. Similarly, if you think you forgot about allergies, you can say that or or anything else, Um, through Zetia. Um, not that it would have changed the kinds of, uh, the management here about Yeah, just just make sure the US about risk. Um, Onda? Yeah, the otherwise, the history is very good. Um, you're you named a good few differential. So generalized anxiety disorder, social phobias, a good shout on also thought like your that line you gave about this The patient summary. Basically, I thought that was very good. And that's basically realistic. Is that how it happens in the ST like you don't have tons of time? You don't even have a full minutes. Sometimes, Teo summarize, you'll just have a few, like, say, 20 seconds and they'll cut you off to move you on that. That was good investigations. We're good, very thorough. So you could do MSG. You can do higher it function. Test on the C G is good. Um, what's your picture? Stomach competitions. That's very reasonable. Um, yes, it will just go through it now. Um, so that's why so far as differential is, you could think about them. A psychological, um, So if there's a few different ones So generalized anxiety disorder Panic disorder, which would be fitting with these kind of, uh, panic attacks. Basically, social phobia, a quarrel phobias. Well, potentially, which is like they're going outdoors and then also OCD could could be on your list and depression organic causes. So there's lots of organic causes, these type of symptoms. So you could say she's taking salbutamol so salbutamol to be two agonist that can make you feel like it can give you palpitations and, um, make you feel anxious. Could be medication induced. She could be having an endocrine cause, like hyper thyroid disease. It could be arrhythmia. You know, you never know. She may be having sgts on day. She also has asked us, so that could explain her accent is shortness of breath. Um, so your investigations really gonna be tailored to your list of differentials and each investigation that you should do that you do should be ruling out your your differentials Not gonna ask in a ski situation. Yeah, It's like a good amount of difference is to give yes. So you don't have to give, like, a full list. You literally I would if you can say there is my top differential. It's generalized anxiety disorder. I could also consider, you know, just one of those other things that social phobia, um, depression and then other organic was I'd like to rule out and just name a couple of things, so that would be like a very good level. I would say, Um, realistically, in ST, I think it's been like a year since I did this is a bit hazy for me, but I think as long as you say that's what one and maybe you want to others like that's fine. And then they will move you on. It's a very, very fast. So, uh, so yeah, Just answer. Yeah. Good. Thank you. Okay. Um, so, yeah, investigations. Did we miss anything? So maybe your pulmonary function tests like spirometry. If you are thinking that this could be like asthma, Uh, I mean, if you were thinking, this could be some other end of crying type of thing. Like they're chromosome tomar that your leg metanephrines. But obviously just say that you said that in your list of differentials. Otherwise, you would, you know, routine. They're gonna do your math. An Afrin is on somewhat presenting with anxiety. Uh huh. Okay, so, um, managing generalized anxiety disorder. So your first line is his CBT, um, on you also just think about this general kind of measures to just psychoeducation mindfulness training, sleep, hygiene, exercise, education. So they're good things to say for any psychotic, sarcastic type of thing, To be honest, um, And then again, the first line medication is gonna be SSRI uh, such a citalopram second line you can given s n all right. Just venlafaxine, um and then this far as socially. Just sign post them, uh, on. But if they if they're having, like, severe anxiety, if there a risk to themselves a risk, the others, then you'll refer them for the community mental health team. Uh huh. Okay, so, uh, we'll switch up now with a different type of case. Um, so I'll just go through this as I did before. So it on the chat, if you'd like to, um, if you'd like to just respond to my questions. Um, So I was asking, Is there fever that form? There is a feedback for world will put it in the chats. Um, were seven forward. So, yeah, we'll we'll put it in there in the next few minutes, I think. Is this fine? Um okay. So less crack on. So 76 year old woman is presents the GP with her daughter, and the daughter is consumed that her mother has bean more forgetful in the past year. So she's that difficulty recalling birthdays, anniversaries. She's not managing with their household tasks such a cooking and paying the bills so her husband passed away a year ago. She feels removed, sometimes low, but denies lack of enjoyment and daily activities. She's know, experiencing any hallucinations on she is struggling to sleep at night. So what kind of questions you want? Ask this this person. So So you know, what's the key thing that I've been saying that we need to assess? We need to assess risk. So, uh, in this patient is a bit different. So they're having it. Seems like some kind of memory loss. Symptoms. So what do we think could, um, could be asked this patient in order to assess your level of risk? Yeah. So effect on daily life. Um okay. So, essentially, what I'm referring to is the functional level. So how well they are. So reward already. Both information how they're kind of cooking to the daily activities. But how are they went? Left alone. Are they doing anything which is on safe to themselves? Are they basically having some kind of self neglect? Um on, Do you know it should being aggressive towards towards anyone else. So it's not always gonna be that the risk assessment is just Are you self farming And are you suicidal? It's, You know, you have to tailor it to what the scenario is. So in this case, the risk assessment is more about a functional capacity on they're doing anything on safe. And so in this case, you say. But she's leaving the gastric, uh, running on several occasions. So she's high risk because she's not showing any aggressive behavior. So past medical history of hypertension, diabetes. She's on some anti hypertensives and the metformin. Um, she doesn't have any family history. She's, um, the next smoker doesn't drink any alcohol this loan. Um, and she doesn't think that she has any problems. You just think so. Daughter's worrying about nothing. So So when we approach the memory loss, it's It's a bit of a different type of history, which I think they definitely could ask. So be prepared for it. Um, and you just stick with the structure, so ask, you know, how long has it been going on for? When did it start? Did anything cause it? Um, And what's the progression like? Is it getting gradually worse? Is it, um, is it like, fluctuating? Is it getting worse in a stepwise manner? Um And then, as I said, So you need to establish the functional level. Are they able to do household tasks by themselves? Um, you need to do the risk assessment. So something else is are are they going wandering around the place? So they, um, engaging in any risky behavior? Maybe they're bit more disinhibited. Um, it's leading to some odd behaviors. Uh huh. So, um, and then your ideas concerns expectations. So always are only I mentioned so much, but always you want to ask at the end, you know about ideas, concerns, expectations. They'll give you marks for it on do this case. You want to know, you know, does the patient have insights? And what's the key concerns of the relatives? Uh, you know where they presented? No. So we've already given some good differentials of memory loss. So, um, one key thing could be dementia. So Alzheimer's dementia is the most common cause. I also think of a vascular dementia and Levi body dementia. So, yeah, essentially, how you're distinguish between those is going to be based on the history. So if it's, you know, common, it's common. So it's most likely to be Alzheimer's. If it came up in the ST but Alzheimer's, characterized by more progressive decline in cognitive function. Basket dimension Dementia is more of a step wise, the client and you don't to see some cardiovascular risk factors in the past. Um, which, to be fair, I did put in some of those just to see if anyone could get to pick up on that. Uh, so what else have you go? Louie bodies. Dementia, which I'm sure some of you, you know, is like a Parkinson's plus type of the dementia. So if they have some features of Parkinson's, eczema's well, we could consider that on. That would also be a characterized by visual hallucinations. So they may be seeing animals on what things like that, um, psychiatric, uh, causes of memory loss would be depression. So if she's lost her husband and she's having a sustained depressive episode that could be causing this, that could be very common and also just a delirium on the background of some kind of infection. Or say, if she's had a change in environment recently, so she may have moved in into her daughter's house, something like that that could be causing start with presentation on then other causes, like neurological causes, would be like a space occupying lesion. For example, if they had some kind of focal neurology, if they have the visual deficits that in conjunction with personality change, it would make you think of space occupying lesion. And then other less likely cause is but just the mention it would be continence or MSA can cause, like, degenerative neurological, um, condition on, then a cephalitis a swell, um, other things. So, basically, like met a ball, it causes so little individual Steven B 12 folate. So I should probably But Bayreuth function there is. Well, hypoglycemia is very important, so that I should probably provide that as well. But, um, yes, so and also just drugs and alcohol is, um okay, so, uh, investigating someone with memory loss do a full examination. You could do MSG is Well, then you'll do your full blood count. Um, he's started for two tests. We talked folate, um, urine, drug screen. So in this case, we could we could consider CT MRI heads. So why would we do that? Yeah, So she could be having subdural. She could be having space occupying lesion and Yeah. So on on an MRI, it would be set. You could look for some cerebral atrophy which would support the diagnosis of, um, dementia on. Been in this case, um, we'll also do a mini mental state examination. So that's the most important thing. There are a few other tests that tools that you can use for diagnosing dementia. So they're called temporal, talkative screen and six item impairment tests. But main thing is mini mental state exam. That's what you need to be aware off. So if I told you that before that the investigations are normal and that mini mental state examination, she's scoring 19 out of 30. What would you think of that? So what do we think they give that in your hands there, though, Does say, you know what does it show? Yeah, moderate. That more generally. What you gonna say? It's showing. Is it normal? Abnormal? Yeah, it is abnormal. So, um, it's anything basically less than 24 is indicative of dementia. It's not diagnostic, but it's, you know, supporting the diagnosis. So about when you would warrant, like, for the referral. Um, anything less than 24 is abnormal. That's the key things you know when you're 18 to 23 is mild cognitive cognitive impairment. 0 17 is severe. So managing Alzheimer's, which, as I said, is the most common things. That's why I'm just that's what about Alzheimer's biopsychosocial approach. It's not gonna be managed in primary care, so it's gonna be a referral to a memory clinic, which is wrong by old a psychiatrist. Uh, so what? One other test for that excuse? It's always good to say, like who you're referring to or what if you say you know, I'm gonna use 80 Approach import from a senior. But what, Senior, you're gonna get input from? Um So yes, it's psychological that the psychological aspect would be these kind of group stimulation therapies or some kind of cognitive rehabilitation. The medicines you can give. So they're acetylcholinesterase inhibitors, such as the neck Oh, galantamine. A reversible rivastigmine second line is the Monty. Um, you know, if there are risk to themselves or others, you can consider prescribing at psychotic drug and socially, they should have assessments by occupational therapist, and so that includes the home safety evaluation. They assessed that transport, driving and self care and is this. Well, then put in. What's a port needs to be put in place for them. So, um, this is a case I have. I'll just quickly run through it because I think we are going a bit over time. Um, so this is quite complex for something that will come up in the ST. But I just want to demonstrate housework through psychosis. Basically. So you got 22 year old male presenting with his mother on day. Spends most of his time home alone? Um, yeah. He used to live independently until a few months ago. Um, and he made some error on his tax. Damon's. He's convinced of the tax authorities of hard detectives to gather information on his whereabouts. He thinks s so he stays this, uh, this is, since his mistake is uncovered on essential for an algorithm which may expose is under printing on taxation system. He's convinced they pride assassins. This guy's bikers, um, after moving in with his mother, he hasn't seen the bikers, but he thinks they're trying to trace his mental activity. Um, he's also heard them aside his house on, but he's heard them talking about how they will kill him on. But he's reported the problems that please, and it's seeking help to defeat the tax collectors he appears suspicious of. With I contact on his question, answers are delayed and he appears internally preoccupied. So but this is, as I said, this is quite a chunky case. I don't think you get something. It's complex and ST. But you know what? What are what? What other thoughts on this as far as what the diagnosis could be. Yeah, So, yeah, this is obviously going to be some kind of psychotic episodes on gum. Yeah, attention. Schizophrenia as well, I think, is the top thing that comes to mind. So I'll just run through a bit about taking history from a psychotic patients. So that's also good. That's a drug induced psychosis. Um, so if you're taking a history from someone with hallucinations, there is when I was talking about symptoms specific questions. So this is where it comes in. So you need to say, like, you need to establish exactly what are the hallucinations saying? You know, you could ask her the male female, but the inside the head are they outside? Um, the other third or second person because that can also help guide you to the diagnosis. So schizophrenia tends to be more third person who's nations were a psychotic depression. It's second person who instillations on. They could be like a prosecutor in nature rather than like paranoid. So, uh, yeah, that's something to bear in mind. With regards to delusions You you can kind of get the patient to explore like explore. The idea is the patient's having, and you need to know. Does the patient have insight into their hallucinations? They know that it's it's not really, Um, and then, as always, you do your risk assessments. So with this, you can just, you know, any thoughts of, uh, self harm suicide and any puts a public others. So I'll say that again. So food person hallucinations are associated with schizophrenia, Start said. It's here, I think. Yes, it's schizophrenia. Ast far as the first round symptoms, it's disorder of thought and perception. So, but with disorder can take three, it's going to take several forms. So thought insertion broadcast withdrawal. I'm not going to give examples of each now, but you can look them up. So thought perception or the door you're loose nations off a third person nature on, then The fourth thing is passivity Phenomenal, which is basically the belief of the body is under control of an external influence. Um, so if you can, uh, if you're having but these one of those symptoms or two of these other symptoms for a totally stop one month, then you can consider schizophrenia is the diagnosis. But as someone a very said on the chance your rights of in in this first case, it's a very reasonable to just say it's the first onset psychosis rather than just jumping to schizophrenia. Diagnosis. Um, so that's good. Um, so ast far as the differentials, what do we think they could be? So we've said about the first onset psychosis. It could be schizophrenia. Could be drug induced. What else could be secondary to bipolar disorder? Exactly. On Daz, I said depression as well. So those are the key differentials, really. So psychosis. First onset psychosis could be secondary to schizophrenic disorder. Could be bipolar disorder. It could be a psychotic depression and then other things as well. Like delirium, um and then also drug induced. That's absolutely right. So if someone's taking steroids. That could be potentially in the form of qualities. The pharmacology stations someone's on steroids that commonly causes, um, commonly causes psychotic symptoms, hallucinations, even people can have, like, visual hallucinations on steroids. So that's something to think about. And then other things, like alcohol withdrawal, uh, space occupying lesion and then, you know, less likely things. But just to mention to the examine, it would be like sle HIV, some kind of water. Um, musicals. Um, so, uh, investigating psychosis. You do a full physical examination. Your MSE full blood. Count your knees. Uh, urine, drug screen, Urinary port is also, if you were suspecting some kind of and the crying cause then you could have elevated quarters. Also, that would be in Cushing's syndrome. So I don't think I said that there, but yeah, you could You could consider question syndrome as well. Um, CT or MRI brain us, as I said previously to look for any space occupying lesion. Um, on, but, uh, I don't believe there's any special tests. So managing a patient with schizophrenia biopsychosocial approach, you consider psychosocial intervention just quite important in this case. So, you know, in Wales, there's ah first onset psychosis team, which you can mention to the Examiner. Other type of, uh, teams that exist are prices, resolution team or home treatment here. But as always, if the patients are risk to themselves or others, then you're gonna need to consider admission under the mental health acted necessary. Um, on that other psychological intervention is that it's CBT, which you sleep is a CBT focused towards delusions or CBT focused. Was there a paranoid ideology? So whatever kind of symptom they're having, which should be addressed by the CB teachers say that how that gives you an edge over anyone just saying CVT, um and then family interventions is Welchol. So be relevant schizophrenia medications that you will give, uh, antipsychotic. It's a first line. So, uh, firstly, you on a typical on psychotic so well as being a type being, um, control on alternative and his treatment resistance gets a premium, then, uh, claws. A P has indicated Stop. Uh, just the scenario here. So let's say that the patient was diagnosed with schizophrenia and he's being impatient for a while, and now he's just discharged on positive. Mean So two weeks later, he's not presenting to the GP complaining a fever, fatigue and a sore throat on These are the blood results. So, uh, just in the chapter of someone wants to put their my corn. Yeah, exactly. So a granular cytosis is where you're looking at here. And how would you manage this? This patient? It was just simple thing you can do. Yeah, get them to ask. That'll. That's very good. And your antibiotics, So yeah, someone. Yeah, exactly. So the key thing I would say Do not forget to say that you will stop the closet. PM So, basically, I had this similar kinds of, uh, this exact same scenario in my ST on I was said all these things I said 80 approach get the senior cycle is on. Whatever, whatever. And then I realized, Oh, I didn't actually stop the clozapine. So, um, first things first stop the closet mean, that's the one thing you can do, even a Zejula on debt. And after that, you do your your 80 approach, you get you a senior import. Um, and then if they're in, they are gonna be an inpatient. So you get the cycles on input with regards to hard to manage from from their own. You know, this psychiatric symptoms on dot This patient is basically having neutropenia on that's causing some some kind of infection. Um, so a septic infection. So sepsis. Six. So one thing that I will say is well, for the ST generally is that sepsis is guaranteed to come up. Um, at least once. So he you know, common is common. And if sepsis is the most common thing, I would say you this should just roll off your tongue, just giving the sex of six. And you know, that's part of a 80 approaches. Well, so you should be really slick. It just really off the steps of six and no hesitating on that point, um so assumes that are there any drugs that you cannot just stop cold turkey? I would say, like if in doubt, it's realistically. What happens is you call the cycle days on team on. Do you ask for advice? But a Zara's? I'm aware if you're if someone's having a granular cytosis what the other example would be if someone started on, um, saying atypical antipsychotic and they're having some kind of fever and muscle rigidity afterwards, that would be That would be, uh Does anyone know what that would be On example? Yeah, exactly. So I'll just say again, in case anyone missed it, if someone started on on, uh, some kind of antipsychotic like lands appeal, and they presents with fever and muscle rigidity, then that's the red flag for, like, the neural Actiq malignant syndrome. So in these kinds of cases, just stop the medication and get senior importers to the west from there. Realistically, if you stop it and then if you hold the medication and then someone tells you often that you shouldn't have held it, then that's funny. You just restarted. They shouldn't be having the medication if they're having that that classic syndrome like that from And I didn't actually cover that today, But you had neuroleptics, malignant syndrome. You just give them fluids and you give them benzodiazepine is a swell. So I covered that in my last psychiatric that in my last presentation. So, um, so So yeah. Um, yeah, exactly. So less quickly finish this up. So, just to mention bipolar disorder, the I think the challenge here in this keyword not necessarily be recognizing that it's a manic episode, but it would be more of the communication side of it. So what? What? The advice I would give us. Just, you know, the testing your communications and listen to the patient for a few minutes is necessary, and they're just talking on and on and on you. Some point, you will need to kind of interrupt them, and that's what they look. People. They want you to kind of gather information as best you can. So assume point, you need to just say, Okay, so there's a few crashes I want to ask you Just ask the questions because the actor may just go on and on and on on. So the questions you want to ask are basically about risk, you know? But they How are they sleeping? Um, are they eating anything so they could be having some kind of self neglect In a manic episode, they're probably not having any self harming or suicidal ideations. So in a manic episode, it's more about their like their functional level. And if they're neglecting themselves on then also you were, you just cover your basis or anything. It's farming others, um, on, but I think they also bean want to ask the difference between mania and hypo mania before, um, so just know the Hypo Mania or I say, mania is characterized by this severe functional impairment. So if they stop going to work, if they haven't Bean engaging in normal daily activities, then it's like severe functional repair mints and also is going off over seven days. So just those two things, uh, you conceive is mainly a hypo mania. And then the additional a swell of psychotic symptoms to say someone's having delusions of grander. So they think they're the king of the world or they're having some boards, regulars, nations then that just makes it may be as well, so otherwise. It's like the similar symptoms of mania, as I said is going for longer. It's causing severe functional impairment on down. There may be some psychotic features as well. Um, and as always, if they are at risk than you consider admission well, I wouldn't particularly worry about bipolar one or by putting the ski. But if you just want to recap, there is, um so if we're managing bipolar biopsychosocial approach, refer them to the community crisis T v a Z, I said admit them it necessary on then, um, the medical management. You start morning horrible antipsychotic medications. To start with, either have a pair of the The Lancet pizza type B. You can try different psychotic, and then third line you add in a little above operates on de sensually. The long term management is gonna be after their manic absolutes come down, then you just see how they're doing. And you can either continue on that therapy or switch to a lithium or, uh, or sodium valproate. But as long as you haven't awareness off that you're not gonna be making that solid decision. So you just need to know, um, do you use your bicycle social approach and say that you'll, uh you'll, uh, refer to the to the psychiatrist? Basically, no. Okay on. Yeah, Psychological interventions are also important. So we say, like high intensity therapy. So it could be family focus therapy or could be CBT um, well, in the stages of cpt. To address their, uh, their delusions and grinds there, for example. Um okay, so just the cover eating disorders. I think this, you know, could potentially come up. I would say less likely compared to the things you've already talked about, but just to mention them. So, um, there's this nickel scoff questionnaire. So, uh, you just memorize these questions. Scoffs that Do you ever make yourself sick? Do you? Have you lost control of how much he reads? He lost more than one stone in a three month period. You could leave it up to the facts. And would you say food dominates your life, So each yes, you get, it's one point on. But if you have a school of two or greater than that's indicating likely e d for example, anoraks. Your believe you know, Rosa the two main ones. Um, just to mention, like I think I did say for the difference you could see with anthrax. And believing is, believe me, A is more, uh, involving episodes of binging with compensate your activity. Uh, whereas anorexia is more, uh, just weight loss on. But the B m I will be low, like lower than 19. Where it's between. You could be low to normal. Bm I, um So the investigations you want to do it with an e d would be a full physical examination. Uh, 12 BCG. Um, but you don't want to take the body weight and height, of course, and work out of the B m I on. Then you're gonna look at the full blood carrots, you know, these are lefties TSP. So hopefully so you do like a nutritional screen, basically, just to see if they're having some some kind of deficiencies which is causing an abnormality in the investigations. Um, so, uh, okay. So other things you could do a urinalysis, a z I said school question there, Um, the management of the needy would be with a psychosocial approach, So I briefly looked in through it today, so I don't think they routinely prescribed any medications for eating disorders. So essentially is referred to a psychiatrist. Um, you you could do, believe me A in Iraq and wrecks your focus. Self help with CBT on family therapy is also quite key in management. E D's, um so this is worth looking over before your risky so they can ask you about admitting patients under the Mental Health Act. So just to quickly recap So the mental help act is applied to patients with psychiatric illness who are risk of harming themselves or other people, and it doesn't have anything to do with capacity. It's just to do with the psychiatric illness, Um on the allows you to treat them without their consent. Um, so the the main wants to know about it's with the with the disk e would be the Section five to, I think, allows you to detain someone in hospital for a period of 72 hours, and that could be by any any cut consultant, basically, so that, or any consultant who's in charge of patients go so it doesn't necessarily have to be a psychiatrist. Basically, that section prior to and then that allows you to arrange for Section two, which is 28 day assessment by two doctors, one of his mental health back to approved on. That could then allow you to arrange this Section three assessment, which is the six month, um uh, term them. It's so that, and that could be renewed. So mainly 52, it's actually 52 and section to four for the inpatient setting. I wouldn't worry too much about these things, these common law section for, um and then lastly. So, as I said, you can technically be asked to explain a drug or treatment or condition. So, um, for for conditions, I would just practice going through the common conditions, like the pressure and schizophrenia. Bipolar. Just practice once or twice explaining that condition to a So you're you're explaining it to the patients or a family member using patient friendly terminology. So you could just look on the NHS website for that. How, Teo exactly Praise it. You should have the knowledge to be able to answer those questions. Just make sure that you're doing in a patient friendly manner. Um so the approach to that station would basically be you just you can start off by asking the patient just a few questions to test ablation what exactly they're experiencing as far as their symptoms on. Then what you tell them will basically be in relation to what they have told you, just like a back and forth. But obviously, you're gonna be doing more of the talking in that type of station. Um, you don't need to assess risk necessarily in this station. So someone did ask about this and I believe that the guy said they're not trying to catch you out. So if it just says explain and it doesn't say, like on the door assesses patients risk, you don't need to do it. So you can take that with a grain of salt if you want, Um, on. But you could ask anyway. But you don't necessarily need to do it. It's mainly just not explaining the drug. And you know what exactly was asked you. So, yeah, talk. If you're explaining a drug, just explained the matter is a mechanism of action in a friendly way. Um, talk about the common side effects on the So you need this for about common side effects that they should expect to experience on. Then, on the other hand, you should talk about the serious side the fax a bit of the patient needs to know about, for example, as we covered clozapine was a grand of psychosis on, So the patient should present they have any effective symptoms and then just ask the patient if they have any questions, address their ideas, concerns expectations on do you. There's that method would trunk and track method where basically, if you're explaining a lot of information, you just explain a little bit at a time. So come onto this table here. My last slide. So you can explain some of these are the kind of broads cat degrees which you can use to explain. So you can explain one thing at a time and just ask. So you understood this. You want to explain back to me in your own words? Just toe ensure that the patient has absorb that everything in the right way. Um, so I haven't did like this. It really isn't exhaustive. But these are, like the most common things that they had asked that the one I would say going look at as well as lithium. Uh, so just have a look at lithium. To be honest, I pulled a lot of this information from the osteo stop book s O. There's a section there where you can see the tables like this on, but, uh, it's very kind of just concise, high yield information, so just familiarize yourself with this. But as I said, I'd be quite surprised that this came up, uh, in the a ski. Um, so, yeah, us, basically everything I heard prepared. Um, so thank you very much for staying. Um Yeah. Sorry. It was a bit rushed. I just come back from elective a couple of days ago. So this was a lot just put together in the last, um, a couple of these, um, so sorry if there's some things you missed, I did put my email on the start. So, honestly, if anyone has any questions, anyone's feelings exactly anxious about the risky, you can just, you know, if you have me on Facebook or, uh, you know, you could give me any questions that you have. No, be happy to help. Um, yeah, that's about it. Slides. And so, yeah, if you have any questions now, you can stay and ask, um and yeah, if you wouldn't mind filling in the feedback form so we can see how we're doing and no, but just to wherever feedback you're giving because we wanted to be a Z useful was it can be Well, no, there's anything and suggest Yeah, Here's my email. Um, so So Okay, look, a Q and A. Is the Mental Health act the same in Scotland? I don't know. I just know about whales. Uh huh. Where it kind of on the slides? We'll make sure today that there was a neurology slides being uploaded. And I'll also be uploading these slides. Just bear with us. Give us, like couple. I was getting, like, an hour, and they will be done I/O. Um, think the mental have act. Might be the same border around only because there's some medicine. And then I'm gonna Yeah. Yeah, that's because sure, um, but it could be good to just maybe right Scotland and then right up. Yeah, I'm guessing. That's, um that's a start. It's medical student. So? So, uh, yeah. Okay, uh, come back since since last year, we'll make sure that those size being uploaded story about the delay. Um, well, aimed to do them by tonight. Just keep on a cow. I think that's been some problem on metal, but it's not letting you access it, So just be patient with us. Um, yeah. And the session man. Yeah. Okay. Thank you very much. Everyone. Thank you to the other Panelists as well for, uh, answering all those questions. You know, we'll see you guys next time on the 30th few days time? Yes. See that