Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, everyone. Can you hear and see me now? Sorry, I'm on two different devices, which is why I'm looking in a different direction. Yeah. Ok, perfect. Ok, so sorry that I'll be working in different ways. I'm just about to share my screen um and then we can get started. Um So I'm just gonna mute myself from here. Ok. Um So welcome to our co blue revision for final session all about psychiatry. Um So I'll share my screen now and you can let me know if you can see it. Um And if you can, we will make a start. Ok? So hope you guys should be able to see that now, I'll just put it in slideshow mode. Um and if someone just pops in the chat, whether they can see it um and if you can, we'll make a start. Yeah. Ok, perfect. So thanks guys, thanks everyone for coming. Um I know that it's a Cold December night, but hopefully um we'll make this as interactive and useful as possible. Um And it will consist of a little bit of osk practice um and also a little bit of theory. Um So yeah, um Welcome guys. Um I'm Karen. I'm currently in F one. I'm on at the moment and I was on general surgery before. Um So just as a quick disclaimer, this teaching doesn't replace any formal teaching by the university where a platform led by students. Um and Code Blue are also partnered with GKI Medics and will be using some GKI Medics stations today for some practice. Um and also the I FMS A and also, so, um so in terms of a quick overview of the talk, um so we'll talk about the main things that you need to know for finals um in terms of conditions, obviously, there's not time to cover everything. Um So I've just tried to pick the things that are the most high yield in terms of Aussies um and also kind of MC Qs. Um So, or quickly just a slide on each talk about depression, um bipolar disorder, schizophrenia, um generalized anxiety disorder, and also dementia. Um And then the bulk of this talk really um is focusing on the osk side of things. Um So history taking how to do an M se um a little bit about the Mental Health Act. Um And then I've got to practice OSK scenarios. Um And then if you guys have any questions or anything you want to recap, um You can let me know um and slides will be given to everybody that fills in the feedback form um which will be automatically sent to you at the end of the talk. Um So just quickly kind of going through a little bit of the theory, this is more kind of like a recap, which is why I've condensed it. Um So in terms of depression, it's really important to think about what symptoms you're actually looking for because yes, depression is kind of, you know, sadness. But what do we actually mean by that? Um And the core symptoms that someone has to have in order to be diagnosed with depression are a low mood that's persistent. Um And this is a key thing if someone has low mood for say a few days, that's not persistent. We're talking about a prolonged period of time. Um Also a lack of energy um that can't be put down to necessarily something else. Obviously, if you're not eating or drinking properly, you might lack energy, but that's more of kind of a cause and effect scenario. So this is a lack of energy with the persistent low mood. Um And then also Anon, does anyone know what Anon is if you do pop it in the chat? Ok. So Anon is basically not finding pleasure and things that you used to enjoy. Um Yeah, perfect. OK. All the comments are coming through now. Yeah, so say for example, if you used to enjoy seeing your friends playing sports, going to the cinema, whatever, um you don't enjoy it anymore. Um So those three things together are what we use to diagnose depression. Um It can also affect people's sleep. So either you find that people wake up really, really early in the morning, so like 3:04 a.m. or you find that they just sleep all the time. Um And also in times of appetite, once again, some people tend to not eat anything at all. Um And other people kind of just tend to eat nonstop. So you either get a picture of someone who's kind of just lost the energy to do anything, they don't eat, they just sleep or you get the opposite. Um It can also affect people's thoughts because they can feel hopeless about themselves and the world and the future. Um and also movement, you tend to see people with depression. If it's really severe, they move slower because they think slower. Um It can also present with kind of guilt, irritability and anger. Um So if you notice that someone um kind of has been feeling a bit low but is also presenting with this, um then you can still have depression in your differentials. Um Just touching on different types of depression, sometimes you can get psychotic depression, which kind of as the name suggests is depression, but also with elements of psychosis as well. Um And also postpartum depression. Um So specifically, if so, for example, in um a scenario, your, you had a patient who'd recently given birth um or really within the last year to 18 months and they're displaying kind of depression symptoms. It's also worth just seeing whether they have any thoughts about their baby because sometimes they can attribute their baby as a source of sadness. They can have thoughts about harming their baby, et cetera. Um And it's also good to just bear in mind for MC QS. Um So overall, in terms of what causes depression at a very fundamental level, it's thought to be because of low levels of serotonin. Um And there's lots of different triggers. And in psychiatry, we use the biopsy social model. Um So when you kind of think about causes and also treatments, you want to be thinking about each of those domains. Um And you can assess how severe it is using the PHQ nine questionnaire. Um You're never gonna be asked to kind of do one and say an exam scenario, but I don't think you will. Um because it's quite long, but it's very good at classifying what type of depression someone's got. Um So in terms of what time the practice is just to answer the question probably in about 15 minutes. Um And you treat it basically using lifestyle interventions. Um So if that doesn't work, you can also offer patients talking therapies, um like CBT. Um and then if nothing's working, you can offer medications. So, um, antidepressants, you've got different ones like SSRI S SNRI S Tricyclics. Um And you'll tailor that towards the patient. Um And before you start anyone on any of these medications, same goes for any psychiatric medications, we always wanna do an ECG um full blood count and then an EGFR as well. Um So in terms of bipolar disorder, so this is recurrent depression and mania or hypermania. Um and the key point of bipolar disorder is that it cycles, it's perfectly normal to feel happy one day and sad one day. But if this keeps on cycling day in day out, then that's kind of when you start to think about classifying this as bipolar disorder. Um And there's also two types. So type one focuses on the manic episode. So you don't necessarily have to have mania and depression of the same degree. Um So with type one, you tend to get a very, very majorly manic episode, but actually the depression might be quite mild. Um And with type two, it's the other way round. So you have a major depressive episode. Um and you tend to get hypomania from a type two, which is when the patients manic, but it doesn't interfere with their functioning as much. Um And you can also have cyclothymia, which is where you've got mild symptoms of both, but they're still rapidly cycling and therefore, it still counts as bipolar disorder um treatment really. The only thing you can do is give medication. Um so you can give patients antipsychotics um to kind of try and help with their symptoms, you can also give them lithium um and sodium valpo to try and stabilize their mood. Um But the key thing in terms of lithium is to screen for toxicity. Um because otherwise you might get patients having tremors, weight gain renal disease, hypercalcemia, um all of which are undesirable anyway. Um but the more toxic it is to a patient that can lead to death and it's actually more common than you think. Um And in terms of sodium valproate. So, in terms of side effects in the early stages, actually, patients tend to have thoughts of deliberate self harm. Um and their symptoms actually get worse. Um Their mania gets worse, their kind of low mood gets worse um before it gets better. So it's just worth kind of warning patients if they're started on this, that actually they'll feel worse before they feel better. It can also cause pancreatitis, which one of those niche M CQ questions. Um And most importantly, it's retinoic. Um And so it can also cause infertility. Um And it's important to tell males and females this just because kind of the mother is the one carrying, you know, a potential child. It's then important to make sure that someone's partner is involved as well. So kind of in an osk situation if you had to explain um sodium val just making that clear to kind of both parties involved in terms of schizophrenia. So this presents with psychosis. Um and symptoms have to be present for at least six months, once again, kind of that prolonged um time period. Um rather than, you know, I don't know, say a day of psychosis um to be times. Schizophrenia. Um and schizophrenia can also um kind of run in families, it's not necessarily inherited, but studies show that you're twice as likely to get it if someone else in your family who's like a 1st, 2nd degree relatives had it. Um And patients usually present with delusions, um also hallucinations um and sometimes thought disorders as well. So kind of maybe thought broadcasting um or thought insertion stuff like that. Um And then schizoaffective disorder, um it's got a really long name, but all this basically means is that you see schizophrenia symptoms combined with bipolar symptoms. Um So if you see that the patient's got schizoaffective disorder, if you break it down, the schizo bit comes from the schizophrenia and the affective disorder comes from that mood disorder, which is the bipolar bit. Um So you can offer patients with schizophrenia CBT. Um and you can also start them on antipsychotics which like we said before, you need to monitor um and you need to continuously monitor it before you start anyone on an antipsychotic, you need to have your baseline bloods and ECG. Um but then you need to keep on checking that as well. Um And does anyone know why particularly an ECG is really important and bloods actually, um but there's one specific thing with the ECG that you wanna be looking out for if you know, pop it in the chat. Yep, good prolonged QT. Um So also in a scenario mainly in M CQ one, if they ever kind of give you an E CG and you need to look at it in terms of a patients that's just been started on a drug, for example, um, nine times out of 10, your answer is gonna be prolonged QT. Um and also for the PSA as well as a side point, if they're ever talking about anti psychotics, um then kind of have a think about prolonged QT um as one of your side effects. Um and you can give patients typical or atypical antipsychotics, um which to be honest, the choices are gonna be based on patient profile. Um typical antipsychotics have more side effects. So like the extra pyramidal side effects. Um So atypical ones are newer and they tend to be tolerated better. Um But once again, it's the psychiatrist that ultimately decides what they're gonna be started on, they all have fairly similar side effects. Um So the most important thing to know for finals really is which receptors these will act on. Do they affect dopamine? Do they affect serotonin? Do they work on both et cetera? Um And cloZAPine is used for treatment resistant schizophrenia. And when we say treatment resistant, we mean if two previous antipsychotics hadn't worked Um but it's a drug to be used with extreme caution because it can cause agranulocytosis. Um So, cloZAPine, it requires lots of monitoring. Patients have to have a book, they have to have really frequent blood tests. Um So you don't wanna start a patient on it unless they absolutely have to be because there's no guaranteed. CloZAPine is going to work either. Um So it's something to be aware of, but you should never be choosing it first line. There's no instance where you would do that. Um So in terms of generalized anxiety disorder, so this is excessive anxiety and worrying. Um And the key thing is that it's out of proportion to the stimulus um because it's normal to be worried about things and have anxiety, but it's when your reaction is way more than it should be. So, say, for example, if you see a spider in the corner of your room and then you're vowed to never enter that room again ever, that's kind of out of proportion to what the stimulus was. Um And it also the most important thing is that it causes a person to not be able to function. For example, when you sit in exam, you might have anxiety and you might be worried, but you can still function because you can still sit the exam. Um and it can also present with restlessness um not being able to focus. Um it can also present with tiredness, which is kind of counterintuitive if you're anxious, but it can, um, also you tend to see patients having palpitations or headaches. Um, and they can also have spotting and tremors, um, and also difficulty sleeping, which makes sense because if you're really worried, you're gonna be up all night thinking about whatever you're worried about. Um, but because these symptoms overlap so much with kind of organic causes, um, it's really important if you're taking a history from someone and you think they might have anxiety disorder to kind of rule out other things. So in your blood to get some T FT S to exclude hyperthyroidism, if you're suspecting cushing's based on other kind of clinical symptoms to do appropriate blood tests. Um and also to rule out substance misuse because recreational drug use, alcohol use can also present with similar sympt. Um So kind of just making sure that in your history you ask about substance misuse, otherwise you might miss the diagnosis. Um It's screened and categorized using the gad seven tool which is similar to the phq nine, but obviously this isn't for depression. Um And really you mo manage it by monitoring it. Um and lifestyle changes. Um And you can offer therapy if needed. Um So when we say monitoring, we kind of just mean watch and wait if it's bad, but it's not too bad. Um then you can kind of just safety net the patient and tell them to represent if they find that it gets significantly worse lifestyle changes. The most kind of common one being try and cut down on your stresses or avoid your stress. Um, and talking therapies once again, um, otherwise you can give patients medications. So once again, you can give SSRI S and S, um, SNRI S, you can also try them on pregabalin, propranolol. Propranolol is mainly for the actual physical symptoms. So, like, for example, if they've got a tremor, give them propranolol, um and also benzos, but once again, they're to be started with caution, especially in people that haven't had these drugs before. Um just going to question in the chat. So the difference between the typical and atypical antipsychotics. Um So the typical ones are older ones that were created in like the fifties sixties. Um and they have lots of extra pyramidal side effects. So things like tardive dyskinesia and your chorea, stuff like that. Um And then your atypicals, they're much better tolerated by patient. But the main problem with atypicals is they cause lots of metabolic side effects. Um So kind of we managed to get rid of everyone's extra pyramidal. Um But instead now people are developing things like hypertension, high cholesterol and diabetes because of being on antipsychotics. Um So that's the main difference. So if in an exam, they're kind of asking you what's more likely to cause a side effect, um then you can kind of work it out from that. Um And really for the other ones, it's just a case of learning a few examples of the typicals and atypicals. Um And then cloZAPine is kind of just a thing on its own. Um And then finally, in terms of dementia, so this isn't one condition, it's like an umbrella term. Um And it results in progressive and irreversible decline in memory, personality, communication and cognition. It doesn't have to affect all of these. But the key point, especially if you're in an osk situation where you're explaining dementia is that it's progressive. So it's not gonna get better and it's irreversible. So, I mean, once someone's got dementia, you can delay kind of it getting worse, but you can't stop it. Ultimately, it will get worse. Um And it's turned early onset if a patient is under 65 otherwise over 65 it's, it's just standard dementia. Um and there's different types of kind of dementias. So I guess the most common one that people know about is Alzheimer's. Um but you've also got vascular dementia. So, I mean, if a patient has kind of got risk factors, like they had a previous stroke, they've got hypertension, um they've kind of got any arrhythmia and you notice a step wise decline in a patient more likely to be vascular. Um Whereas if it's kind of just like a completely gradual, natural progressive decline, it's more likely to be Alzheimer's. Um and Alzheimer's as well tends to kind of run in the family more whereas vascular, I mean, it's really just up to, you know, the patient, if you look at their past medical history and their drug history can usually get an inkling of what type it's gonna be. Um, and then Parkinson's and Lewy body kind of go hand in hand. Um, so Parkinson's dementia is when someone starts off with the motor symptoms of Parkinson's um, disease and then you get a cognitive decline. Um And then Lewy body dementia is just the opposite way around. You start with a cognitive decline and then you get the Parkinsonian symptoms. Um And then there's also frontotemporal dementia, which is as common, but it's mainly associated with personality kind of changes. So you might actually find someone's memory is ok, but the personality is completely changed and they're agitated, they're disinhibited. Um And they're just very aggressive and violent. Um You're kind of more leaning towards frontotemporal dementia, um and risk factors. Um This is mainly for vascular dementia. Um But lack of it, exercise, hypertension, high cholesterol diabetes. Um and also stress stress can really precipitate any kind of psychiatric disorder. Um But I mean, it's just a good one to be aware of if you're history taking and you have time to just ask if your patient is stressed or not because something that might not ordinarily trigger someone who's not particularly under high stress might actually be the straw that breaks the camel's back in someone who already is um and to diagnose dementia. So first of all, you need to take a clinical history and then you need to do a formal cognitive assessment. Um So the most common one is the ace three or if they're so impaired that you can't kind of do that, you can use a mini ace. So the ace three is out of 100 and the mini ace is only out of 30. So it's a lot shorter. Um So patients tend to tolerate it a lot better. You can also use the mocha um or N GP, you can use the GP COG. Um And if a patient English isn't their first language or they left school early, then you can use the ra score as well, which are stuff that you don't really need any background knowledge for. It's things like if you were crossing the road, what would you need to think about? Um or can you touch your left shoulder, your right foot, et cetera. Um And in terms of management because it's irreversible, what you really need to do is just make sure like the legalities and the admin side of things are sorted. So does the patient have a will, does the patient have an advanced directive? Does the patient have lasting power of attorney? All of that stuff? Because if they lose capacity, then I if they don't have these things in place, it can be very difficult to decide how to manage treatment. Um Some cases you can try Donepezil and memantine. Um but you only do this if you think that there's gonna be kind of er improvement in return to functioning. Um Otherwise, if people have loss of comorbidities um or they're quite old, um or the level of functioning is already low, um you tend not to try medication um and to manage kind of the side effects. Um and other presentations of dementia, you can also use antidepressants, antipsychotics and benzos. So say, for example, if a patient is really agitated because of their dementia, you could give them some Benzos um or if they're really upset because they're having a personality change, you could give them antidepressants. Um but you only really treat what you see. If someone's not presenting with these symptoms, you don't have to put them on there. You can kind of let them be and kind of just live peacefully. Um So now we'll go on to the osk side of things, which is the bulk of the talk. Um So in terms of history taking, we'll kind of just go through this quickly. Um because most of it is what you'll already be used to doing. But for a psychiatric history, um there are just a few extra things that you need to put in. Um not anything kind of for an ay that you know, means you need to do your rail, the rest of your history um but just one or two things, but if you were in the community in your F one F two, actually taking histories, then you need to do like a proper history and document it. Um So the first thing to do is to check the patient's details. Um And obviously introduce yourself as you would for literally any patient. So you need their identifiers, name, date of birth. Um You also need to know why you're seeing them. Have they been referred to you through A&E have they self presented? Have they been referred to you through the GP? Like why are you seeing them and why now? Um and also what's their legal status? So by that, we mean, are they under the Mental Health Act? Um Are they kind of here from prison? Um stuff like that because it's important to know um especially in psychiatric patients. Um But really for any patient you see. Um So then in terms of the presenting complaint, why is the patient now? Why are you seeing them? Um And it's important to then delve into the history of the presenting complaint. So what's led up to this presentation now? Like with psychiatry, the massive thing is what, why are you presenting now and what's happened? Um So how did they present? Did they once again, like we said before, did they kind of just peacefully present which tends not to happen? Um Were they sectioned? Oh OK. Let me just get rid of this. There we go. Um, ok, there we go. Um, or did they kind of have, um, other circumstances that brought them there? Um And has this happened before you tend to when you're working? Especially in acute settings, like A&E say? Oh, so, and so's back again, you tend to get the same people, people coming back. Um, but it's like the boy who cried wolf, you can't just ignore them because the one time you don't investigate in full detail might be the one time something has actually happened. Um So it's important to just know whether they've presented before or not. Um And then you need to know about the past psychiatric history because they might not necessarily always tell you. Um So things like, have they ever had nonacute presentations, have they say been to the GP and been diagnosed with maybe depression? Um Or when we say acute presentations really? Have they been sectioned or have they had an inpatient stay um compared to say, community treatment for their mental health? Um So, yeah, any previous diagnoses really, they might not tell you, but it's important to ask dependent or what they present with. Say, for example, you've got a patient who's paranoid, probably not gonna tell you. Whereas if you've got someone who's maybe anxious or depressed that probably a bit more likely to tell you um past medical history just as you usually would. Um And it helps you to rule out if the presentation is psychiatric in nature. So say, for example, you see someone and they see worried and they're sweating, they have tremors, but then you find out they have hyperthyroidism, you're thinking about other causes potentially than just anxiety. Tons of medications. Same thing once again, um, important to check allergies and intolerances. Um, and it's particularly important to check for any psychiatric medications. Say, for example, someone tells you that on, you know, antipsychotics and they still present to you with psychosis, always check if they've been taking their medication. Same thing for people on antidepressants, they take them and then they say they feel better so they stop taking them and then you kind of just get the same cycle of symptoms happening again. Um family history. So knowing if there's any genetic conditions, um or any psychiatric conditions, um or adverse childhood experiences. So these are things like your parents getting divorced, being a victim, um, of kind of abuse, stuff like that. Um Things that are more likely to predispose you to becoming mentally ill. Um Once again, they might not always tell you, but it's important to ask. Um And then the main difference between a psychiatric history and a normal kind of everyday physical health orientated history is the personal history bit because you don't tend to ask about most of this stuff, maybe like work and relationships um in a normal history. But here you need to go from their conception to their birth schooling, work relationships, and most importantly, their premorbid personality. Um There's nothing as powerful as asking a person what they were like before. So if you wanna check premorbid personality, you can just say, and before you became ill, how would your friends have described you because you need to know what their baseline is if someone presents as really upset, but then you find out they're always kind of a bit low in mood. That's not as concerning as someone who is usually really happy, really bubbly and now suddenly just struggling to get words out of them. Um, social history. So where do they live? Um, finances, what are their finances like, say, for example, someone's manic and they've just spent all of their life savings. How are they gonna eat? Where are they gonna live? Um, et cetera, um, mobility. Um, and then your usual smoking, alcohol, drugs to see whether that's factoring into their presentation. Um, and then the other thing which is kind of a little bit different compared to other histories is the forensic bit. Um, has there been any police involvement? Um, any court involvement, um, in terms of safeguarding, are they known to social services? Um, and the biggest thing that you need to do at the end of this really is assess risk, um, in every oy, you'll be asked to classify the risk between low, moderate and severe, um, based off what they've told you Um, so if there's anything concerning you from the history you've taken, um, then you're more likely to put them at moderate and severe. Um, obviously you won't 100% know if they're telling you the truth. But generally you can get a feel of whether someone's kind of low risk, you feel like they could be managed in the community or higher risk and perhaps they need to be admitted. Um, so now we'll talk about the MSC. Um because for psychiatry, there's not really a physical exam you can do. Um And the M SE, some bits are subjective, some bits are quite objective. Um So we'll quickly just go through how to do it. Um And it depends in different Unis Manchester. If anyone hears from Manchester, um if you do have to do an M SE, you tend to do it on a video. Um So just make sure you kind of don't zone out and watch the video, but at other UNIS, I know that they kind of have actors. Um so different unis do it in different ways. Um So the first thing for your M SE um it starts as soon as you see the patient, it's not like kind of other say ward rounds where you know, you go there, you close the curtain and then you start the conversation as soon as you lay eyes on the patient, your M SE has started. Um And even if the patient doesn't engage with you. You can still do an M SE. Sometimes people say, well, the patient didn't talk to me so I couldn't examine them but them not talking to you. Is your M se in a nutshell? Um, so how's patient dressed? Are they dressed appropriately? Um, or are they just completely inappropriately? You know, someone in a tshirt and shorts walking around in the snow? Um, or do they seem like, you know, they have kind of a good handle on how to dress for the weather. Does the patient look hygienic? Does it look like they're practicing regular self care? Um, or does it look like they've potentially not showered for a week because that'll give you an insight into, um, their energy levels. Um, and also whether they kind of are engaged with their daily routine. Um, where is the patient as well? Are you seeing them sat up full of energy? Are you seeing them slumped in bed? Um, are you kind of seeing them in their own bedroom? Are you seeing them in a day room, et cetera? Um, and any signs of any physical abnormalities? So kind of self harm, drug use, et cetera, um, in terms of behavior. So is the patient engaging, even if they're not, it's fine, you can encourage them, but if they really don't wanna talk to you, you can still continue, um, and do a messy, that's fine. Um, you also wanna check for any psychomotor abnormalities are they moving particularly quickly or particularly slowly at all? Um And what's their body language like? Are they um making eye contact with you? Are they facing you? Are they turning away? Are they looking at the floor kind of what, what is that overall behavior like? Because that gives you a really good insight into what the patient's thinking um in terms of speech, the judging whether the speech is fluent, um does it kind of all just come out and flow or is it really staccato? Um And is the speech coherent patient might be talking? But you might not necessarily understand them, but it's important them to categorize whether that's say maybe a language barrier um or, you know, kind of regional dialect or whether they just are not actually making sense and they're actually not coherent. Um And then you can assess tone, speed, rhythm volume and also how much speech there is. If they've got Algia, which is poverty of speech, then you're probably gonna get one word answers. Um Whereas if someone's manic, you might find that they have pressured speech, which is just when they keep talking and talking and even if you try and cut them off, they'll just keep talking. Um And then in terms of emotion, um so you wanna have a look at their mood, which is what they tell you their feelings. So they might say I feel happy today. Um And then you also wanna look at the effect, which is what you think. Um So it's kind of subjective, so they might say they feel happy, but when you look, look at them, actually, they look quite sad. So their affects and their mood aren't congruent. Um And you also wanna see whether their emotions are la are they really happy? One minute, really sad, sobbing the next um Or is it kind of consistent um and not fluctuating? Um And then in terms of perception, so this is really important, you wanna see whether there are any hallucinations um or any pseudo hallucinations. Um And you wanna have a look if there's any depersonalization. Um So, are they kind of seeing themselves through someone else's eyes or are they kind of engaged with being in their own body and being present? Um and just checking for any overall through changes? Um And the easiest way to do it is just checking if they're responding to any unseen stimuli at all. Um Because if they start talking to themselves, um or they start kind of touching random things, then, you know, you can follow up and say, you know, who are you talking to or kind of what are you touching? Um in terms of thought. So how quickly are they thinking? Um And do the thoughts make sense? Are they coherent? Um And whether the thoughts flow or not, sometimes you might start thinking about something and then you can kind of stay focused on that topic, um, or their thoughts kind of jumping around to kind of like night to move thinking. Um And what the content of the thoughts are, are they kind of happy things like their family or their friends or are they kind of thoughts of deliberate self harm, suicide stuff like that? Um And don't be afraid to ask what they're thinking, um, because without prompting, they might not tell you and you don't wanna miss something really important. So for example, you didn't ask and actually they had suicidal ideation all along. Um And also just seeing if there are any abnormalities of thought possession, it's kind of like we said before, is there thought insertion, is there thought withdrawal? Do they feel like their thoughts are their own stuff like that? Um And then in terms of insight, this is really important. So, I mean, does the patient think there's a problem? Um And does the patient think they actually need help because this is gonna dictate how much they engage with you? It's really common for patients to say they feel like they're a prisoner and that there's nothing wrong with them. Um And that they've just been admitted for no reason. Um And kind of checking whether the patient shows overall situation or judgment, say, for example, you're thinking of giving someone leave, but they don't think they're ill. So you don't think they're gonna take that antipsychotics, you've gotta think, are they actually safe to be in the community? Are they a danger to themselves or others? Um And then cognition. So, I mean, is the patient orientated to place person time? Does the patient remember things? Um And does the patient actually have capacity? Um or not? Um So once again, based on your m se you can calculate kind of what you think the risk um to themselves or others, the patient is um and then act accordingly. Um And then just a quick bit on the Mental Health Act before we go on to the OSK practice. Um So it allows people to be treated without the consent. Um And it's used when a person is a risk to themselves or others and you can use it in acute or non acute situations. Um and patients that are treated under the mental health acts can still have leave. So for example, even if they, they've been sectioned and they've ended up in a psychiatric hospital, it's not that they're kind of trapped and they can't leave. Um if certain criteria are met, they can still have leave. Um And sections can be appealed as well. Um If the patient's act of kin or the patient themselves think um that they've been wrongfully sectioned, you've got half of the duration to appeal it. So say for, for example, if you are under section two, you've got 14 days, um Section three, you've got three months. Um And if you want to appeal it, it's a formal process and it will go to tribunal. Um and you need to get solicitors and judges involved. So patients, it's quite common for them to try and appeal it. But in terms of how many actually make it to a tribunal, it's not that many. Um So I won't go into too much detail now because this slide is quite nice and succinct, there's loads of different sections, but for kind of finals, these are the kind of ones I'd say you need to know. Um So section two is for assessment and treatment. Section three is for treatment. But if at the end of your section two, you've still not done everything you needed to do. It usually just gets changed to a section three. Um Section 136 usually used by the police. Um and it's removal to a place of safety, which in this scenario is usually either a police station or a hospital, say, for example, someone's found wandering around, someone's on the road, someone's on the motorway, et cetera or they're about to jump off a building. Um And then the most common thing um as an F two or above you'll get asked to do is 52, a patient which is when they're an inpatient. Um and you need to section them. Um and 54 are what nurses can do, which is the same thing. Um But a 54 is only valid for six hours uh whereas a 52 is valid for 72. Um, ok, so the first practice oy station is the history taking station. Um Does anyone want to have a go at this? We'll be using ki medics um stations. Um, so if anyone does just pop it in the chat, um, and we can get started and does anyone wanna have a go? Don't be shy? It's all good practice. Yep. Ok, perfect. We have a volunteer. Brilliant. Um, so you can whenever you're ready, I'm just gonna invite you to the main stage. Um, so invite to stage. There we go. Thank you very much for volunteering. Um It's really useful to kind of do these. I know it can kind of seem scary or you know, or when it's a Monday evening and it's late, just can't be bothered but it is really good practice. Um So hopefully DW is gonna join us on the main stage so they just accept the invite and up that you are. Ok, perfect. Um Just try speaking. Ok. Yeah. Yeah, perfect. I can hear you. Um So what I'm gonna do is I'm gonna keep showing. Um ok, so I'll let you just have a read of the stem. Um and then whenever you're ready, I'm just gonna start a timer for eight minutes. Eight minutes is what Manchester uses. Obviously other Unis um vary if you finish before eight minutes, that's completely fine. Um But eight minutes is kind of just a guide. Um, so I'm gonna let you do your thing. So I'm just gonna get, um, the station up because like I said, this is, uh, a proper geeky medic station. Um, so I'm just gonna get it up. Um, and then we can begin. But, yeah, thank you very much for volunteering. Um, and everyone else watching kind of think about if there's anything you do differently, any questions that you would ask, um, or anything that I would ask that you're like, oh, actually, you know, that's, that's a really good thing that I wouldn't have thought to ask. Um, ok, perfect. So whenever you're ready, take it away. Hello. My name is, I'm one of the doctors working here. Can I get your full name and date of birth, please? Yeah. So it's Belinda Brain and it's the 26th of February. Um, and I'm 33. Nice to meet you. So, what's kind of brought you in today? Um, so I've just been feeling a bit low in mood really? Um, and I've just been feeling a bit more anxious as well. Um, ok. Could you just tell me a bit more about how you feel and feeling? Yeah. I mean, kind of, I've just been feeling a bit low. Um, and, and I don't really know why, to be honest. So I just thought I'd just come and speak to speak to a doctor. Really? Yeah. Yeah. And, and just regarding the little mood, just tell me when it started. How has it developed. Um, I mean, to be honest, it's been for like the past six months. Um, ever since I lost my job as a retail worker. Um, so it's, it's kind of just carried on. I thought I'd be ok, but I should feel worse. Ok. I'm sorry to hear about you losing your job and in terms of your low mood, how would you say that's affecting you on like, a day to day basis? Um, I mean, that's a good question. I've not really thought about it, to be honest. I guess it's just kind of taking over my whole life. I mean, I just feel low and sad all the time and that's not usually like me. Mm. Would you say it's impacted your energy levels as well? Yeah. So, I mean, it's, it's definitely made me lower in energy. Um, and I just feel like I'm always just really unproductive. I don't wanna do anything. It's, yeah, it's just not like me. Yeah. And because of this, have you maybe lost interest in activities or hobbies you used to like to do? Um, no, I'm still managing to kind of, you know, do things that I enjoy, um, as much as I can. Um, I enjoy them slightly less but, I mean, I think it's just because I'm a bit more tired really. Um, ok. And in terms of the low mood, has it affected your sleep. Um, not really to be honest. I mean, now that I don't have a job I can kind of sleep whenever I want. Um, but I mean, you know, I kind of, I think have a good sleep schedule and how about your appetite has not been affected? Um, I mean, yeah, I suppose I'm, I'm not really eating that much. Um, but, you know, that's, that's normal. Right. Yeah. And some people, when they feel low they have, they have trouble concentrating on certain things or conversations. Have you noticed that? Yeah. I mean, I do struggle now to kind of focus because when I used to work in the shop I had things to focus on. Um, and now honestly people will be talking like you're talking to me right now and I'm kind of, you know, zoning out. I just, I just don't know why. Hm. Ok. And earlier you mentioned to me that you feel anxious alongside this little room. Can you just tell me more about that? Yeah. I mean, you know, being fired from your job isn't, you know, good. And I just feel like I'm a bit of a failure and I'm just worried I've been trying for so long to try and find a job and I just haven't, so am I ever gonna find a job or am I just gonna be employed? II don't know. Mm. Yeah. I'm sorry to hear that the last few months do sound difficult and it all seems to be having a toll on you. And yeah, I just like to hear that really. Yeah, I just, I just don't know what to do. Doc. Mm OK. And just regarding the anxi anxiety again, would you say this is a constant feeling you have of kind of just anxiety and worries. Um I mean, sometimes it comes and goes but like I've started kind of getting really bad chest pain. Um and II don't know why. And I also, I don't know if this is related or not, but I also kind of just always feel a little bit lightheaded. Um and that's, that's not usually like me, I suppose it's the new me. But yeah, I just don't know, like chest pain, lightheadedness, like, is that normal? Yeah, just, just in terms of these symptoms just so I can get on some more about them and understand what's causing this. Does anything in particular trigger them or can they just come out of the blue? Um I mean, to be honest, they kind of just usually come out of nowhere. Um, so, I mean, they, they kind of come and go so I've not bothered to get them checked out. You're actually the first doctor I've told about them. Um, but I just, I just don't really know why I'm getting them. Mm. And have you found yourself um um pointing off certain things or avoiding certain situations because it can trigger you to feel anxious or low in mood. Not really, to be honest. Uh I've not noticed anything in particular. Ok. And apart from um, the anxiety and the low mood, as well as these physical symptoms you mentioned, has anything else been bothering you for the last few months? Not really. I just, I really want to drop again, to be honest and II just don't know how to get 10, ok. Um, oh, actually there is. Oh no, I don't think it's relevant actually. Never mind. Ok. Well, maybe it could be relevant with, you know, we just, why don't you discuss it? It would be helpful. Ok. Um Well, me, me and my partner um, recently separated um and, and also had um a bereavement in my family. So II do think that's relevant. I mean, why would that cause me chest pain? Um But I suppose whilst we're talking that that has happened. Yeah. Ok. Yeah. I'm sorry to hear that again. It just feels like a lot of things going on at once, isn't it? Um, in your life at the moment? Mhm. Yeah. And would you say all this kind of has made you feel quite stressed as well? Yeah, I mean, you know, I feel like in this day and age we're all all stressed all the time. Um But yeah, II feel like I'm more stressed than I ever used to be cause I'm, I'm just so worried all the time. OK, and I'm just going to ask a bit sensitive questions if that's ok. Um, um, so have you ever, um, heard or seen anything? Maybe other people can't, I don't think so. No. And because of, um, this low mood and anxiety, has it ever caused you to have any thoughts of possibly harming yourself? I mean, once or twice. Yeah, but that's normal. Right. You know, when you're a bit worried you kind of just think that, ok, and when you've had these thoughts, have you taken any actions or thought about acting on them or are they just kind of feeding thoughts in your head? No, no, II never act on them. I think they're kind of just thoughts I get for maybe 10 seconds. Like the world would be better if I wasn't in it. And then II stopped thinking that. Ok. And because of this, have you been still able to kind of look after yourself, like cleaning and cooking and just going about your life independently? Yeah. I mean, like I said, I mean, I don't, I don't really have to worry about cooking because I'm, I'm not really eating. Um, but in terms of cleaning. Yeah, I think II have a nice, uh, house feels a bit lonely now that it's just me in it. But whatever I suppose that's life. Ok. And, um, do you have a past medical history of any, um, medical conditions you've been diagnosed with in the past No, nothing, nothing. And have you ever had any sort of mental health struggles, any low mood in the past, or has this been the first occasion over the last few months? Yeah. This is the first time that I think it's significant enough, I've had to come to the doctors otherwise it's been like, you know, one or two days and then I'm fine. Ok. And are you taking any medications at the moment? No, I don't take anything. And do you have any allergies? Um yeah, so I'm allergic to penicillin, penicillin. And do you have a family history of any health conditions? Um so my mom had a heart attack a year ago. Mhm. Any family history of any mental health conditions? Not that I know of. Ok. And just in regards to your social life, um do you smoke or drink alcohol at the moment? No, I don't. Ok. Any illicit cookies. Uh no. Ok, cool. I'm just going to stop it there cause that's been eight minutes. Um but overall that was really, really good. Um So um in terms of differential diagnoses, um what are you thinking? Um for Belinda. Yeah, I think mainly I'm considering a major depressive episode, major depressive disorder due to like the combination of the low mood, low energy um and just kind of the way she's describing is affecting her sleep and appetite. So, yeah. Oh and do you have any other diagnosis potentially? Yeah, I was considering the possibility of um generalized anxiety disorder. So because she has no underlying anxiety um as well as kind of chest pain, palpitations, lightheadedness, which can be the physical symptoms of the anxiety as well. I also consider having a panic disorder because she mentioned um these physical symptoms come out of the blue without any cause, but that wasn't kind of explained at a low mood or low energy. Yep. Perfect. Um And in terms of a management plan, what would you do? So, I think in this case, um the depression is kind of quite severe now because she's had physical to self harm as well, but you'd start with kind of um self health education about the condition. Um and then moving on to kind of CBT referral, the use of SSRI and kind of um in the next two or four weeks, calling them back to the GP to assess the improvement. Yeah, really good, well done. Um So overall that was really good. Um So in terms of your management plan, yeah, really sensible stuff. Um and the key thing is to always bring them back um because otherwise patients kind of sometimes feel quite lost. Um So you always want to rereview them. Um And if you start them on any new medication, you need to review them in, yep, two weeks and then four weeks. Um in terms of the history overall, I think it was good. Um Obviously lots of kind of content to pack in. So I think you did really well. Um something to always ask if you've got a patient with depressive symptoms is to also screen for any manic symptoms because this could have actually been bipolar disorder. Um But if you don't kind of ask about mania, um then you might not know, for example, she could just be in a depressive episode now, but actually tomorrow she switches to a manic state. Um So it's always just worth asking that. Um And another thing as well, if someone's telling you um that quite a lot of things have happened in their life recently, um you can always use adjustment disorder as a differential because I mean, to have lost your job and to have broken up with your partner and to have been bereaved. Um you know, it, it's a lot and it's kind of like a natural stress reaction and she did say that she was feeling stressed. Um And the only other thing really to kind of pick up on is that um she mentioned twice that she wasn't really eating. Um So when you've got someone who's got kind of chest pain, lightheadedness and they're saying they're not eating, they're not cooking kind of just exploring a little bit more about that. Is this actually an eating disorder that's being masked kind of by something else, potentially or going on at the side. But otherwise, yeah, your differentials were all very sensible Um, and your management plan was, was sensible as well. So, yeah, overall, very good stuff. Um, so thank you very much for volunteering. Um, there's one more station, if anyone wants to do it, um, I'll let everyone just have a little read of what the station is. Um, and then if anyone wants to have a go once again it, you keep me station, they've just changed the names. Um, so yeah, you can pop it in the chat and then we can start. Um And this is the last um practice station. So it's the last chance to kind of just, you know, see what happens, even if it doesn't go as you would, it's better for that to happen now than in your real ay. So if anyone does want to do it, just pop it in the comments, um And then we can kind of start. Um and then that all round off the talk. Um But I'm not gonna force anyone to do it. So if no one's keen, we can kind of just spend a couple of minutes talking about potentially how to structure it. So I'll give it maybe 10 more seconds if not. Um Then in the comments instead, if you just pop in things that you think you potentially would mention. Um So yeah, if you just have 30 seconds to put in things that you think you discuss, um then we can just go through it and make sure that everyone's happy with kind of how to approach conversations like this because they seem really easy on the surface. But actually once you get in there having to explain sensitive things like these to next of kin can actually become really difficult. Ok. Four. Yep. Good brief history of what, what patient, anything else that you would do? I know it's late on a Monday, so I won't keep you guys for too long. Um Cool. OK, so we've got the start of what we would do. Um So we'll just kind of chat through it. So the first thing is to obviously confirm the identity of the next of kin. Um And then kind of following on from that to work out. Yeah. What's actually happened to Martin mind? Why has he been sectioned? Um and kind of just established that that history, see what the next of kin knows um for an osk situation, they'll know something. Um And then kind of following on from that just explaining a little bit about who you are and what you're gonna talk about. Um And then really, in terms of a section, you wanna explain what the mental health act is, you wanna explain specifically what a section two is so kind of what it's actually used for and how long it lasts. Um And then also what happens if they want to appeal and also what happens if the section two runs out? What what happens if they just get released or do they stay in? Um And then they'll have questions to ask. Um If we're not gonna do the station properly, I won't kind of put in these questions because if you wanna refer back to this slide later when it's closer to finals for practice, um I'll leave those for then. Um but yeah, basically they'll always come up with questions like little curveball questions that will throw you off course. Um And if you don't know, kind of be honest, just say you don't know, they're not gonna penalize you, it's much better to say, you don't know and not say something just completely wrong. Um So that's always something useful. Um And usually you'll get next of kin who are either really, really upset or they're really, really agitated because obviously sectioning mental health, that's a very emotive subject. Um So it's also just about kind of either calming them down um or making them feel more at ease. Um Because if you can go from a start of the consultation where they're kind of not really cooperative to actually at the end of the consultation when they're thanking you and they're happy with the outcome that shows, you know, good communication, good empathy, et cetera. Um So, yeah, um in terms of the questions they have, obviously, yeah, you know, you're gonna get a few nice little curve balls in there, but otherwise everything else just make sure you explain it in jargon free terms. Um And you summarize at the end, that's the most important thing. Um You can get them to repeat it back to you, but you just need to show whoever is examining your OS station that the patient has retained what you've said because you've explained it clearly enough. Um because that's what you need to do in real life as well. Um OK, so obviously that was a really brief overview of how to approach this. Um But hopefully that was a useful whistle stop tour er section explanation. Um So thank you very much for listening. Like I said, feedback forms um will automatically be sent out um and it's really useful for portfolio. So please, if you er can fill it in and you'll get the slides in return. Um And if anyone has any questions, either about anything from today, um or um f one et cetera, I'll stay on the call for a couple of minutes. Um But if not, I hope everyone has a lovely evening and thank you for coming. Um And we're doing code blue finals revision every Monday at seven. So make sure to tune into our next ones. Um So yeah, I'll keep the chat open um for another couple of minutes. Um But if not have a good evening. Yep. So there is a feedback form. So like I said, it will be automatically sent out to everyone. Um And if you fill it in, um you'll get the slides. Perfect. If there's no more questions, I think we'll end it there. So, thank you everyone. Um and have a lovely rest of your.