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Hello. Is it working? Everything seems to be a little bit different uh, when it was a couple of, uh, months ago. Can anyone hear me in my back? Hello? Ok. Oh, thank you. Um, ok. It's been a while. Um, and we've got a, you probably don't need me reminding you. We've got a couple of weeks until the uh the sy obviously, um we won't start until about five minutes in, but given that we've got this mental how, how we all feel and how's it going as brilliantly as you all hoped? I don't know about you. I started my year four with this plan of, oh, I'm gonna start revision in September. It's gonna be awesome. I want to cover the things eight times by the time I get to the exam didn't start till like what? So we'll wait until um five pass until just to let people filter in. I know the last one that I did with this was data interpretation, which was a while ago and that went on forever for anybody who's stuck around to the end of that. I applaud your stamina. This one should not be this long. Anyone wanna rep, respond to that ment. You don't have to, I can put it as a poll actually. How are you feeling? Ok. Got some people in on the thing of overwhelming, scared. Absolutely terrified. Which, yeah, it, it is like that. I wish I could, I wish I could offer advice. That would actually make it less scary. Um, on the plus side, you've probably done it a few times now with the mocks and whatnot. I hadn't done a mock. I just did my ski. Um, so a little bit more prepared than I, uh, I was. Um, and hopefully you've had, I know that there's this session, I think. I know there's, is 101. I think Os obviously is doing stuff. Um, and hopefully you've had a lot of support where the, uh, the university may have, uh, dropped the ball a little bit because I feel like everyone feels like the ball gets dropped on stuff. Um, so today we'll be going through, um, common and important stuff. So I've just decided to do it in, in the format of ey, um, stations because that's what you're revising for. Um, and I've tried to do it in the Cardiff format because you're not revising for a London. Ay. Um, so I've laid them all out like Cardiff Stations. I've picked common important things that we can go through. Um, I've got the interactive stuff. I've got the chat open. I've got the mentee, the mentee up. There's a question thing on ment where you can submit anonymous questions there. You got questions in this chat here where I'll see them and I've obviously got the questions on the ment coming up on slides as well. So if you want to interact, I have all of the options, all of the ways that you can possibly interact. Um But it's gonna sound really cringe my recommendation for this is I'm going to ask questions that are like is questions and whilst I would love to have interaction from you in the audience, the best thing that you can do is completely ignore me entirely and say out loud or think in your head if you don't want to say out loud, what your answer would be to that question, push comes to shove you're in the iy of what you're gonna do cos that's, that's gonna be the best bit of practice for you. It's gonna be awkward and I'll probably sit here in silence a lot. You can submit stuff on the questions and stuff if you want as well. Um But yeah, it might be a bit crunch, especially if you've got other people in the room with you. Um But I think it would be useful. OK. Right. We got five minutes past. So let's get going. Um So like I said, still got this mentee in the corner. If you want to send messages on the chat, please do. Um And then we've also got the the actual mentee questions. So we're looking at specific example cases focusing on common and important presentations. And then we've got some answer structures and I've got summary sheets for the conditions that we go through. Like I said, questions in the chat, questions on mental wherever you wanna shove them. Um So um station one. Um so this is the bit that would be outside the door, take your two minutes to read it. It will be less than two minutes. But, and like I said before, my recommendation to you when you are standing during this two minutes is one, make sure you read it, right? Make sure you actually read what it says. Two know where you are, it would be unreasonable to say I'm going to do an ABG as an investigation if I'm in GP, right? So know where you are so that you can talk about the context. If you forget where you are, you can always ask the examiner. But obviously, the more prepared you are, the more you remember that the better off you're gonna be as we stand outside. So we're thinking about where we are and we're thinking just reading the patient details. What do I think this is? He's a 19 year old with abdominal pain, right? So in my head, I'm just gonna run through differentials for abdominal pain. I'm gonna be trying to figure out what type of history am I taking here. Now, this seems like a generalized history. It's probably going down the route of a gi one. That's the thing I'm thinking. But we've got a young woman and is exams like to be a little bit stereotypical. So also this might be going down the route of like gyne ectopic pregnancies, obstetrics, that sort of stuff as well. Right. So, those are my two main ones. There could be some rogue ones, but broadly, I'm probably thinking this is some sort of abdominal pathology, right? So I'm preparing for Abdur stuff. So, um, you know what? Haven't done that? I'm gonna scoot back. I've changed the, the page over on the, um, on the mental, what questions do you want to ask to this person? 19 year old, 19 year old acute surgery. We're in the emergency department? Abdominal pain. What do we wanna ask? Oops, sorry. What questions do we wanna ask? Where the pain started? Vomiting? Mhm. Could you be pregnant? Yeah. The person who's written, could you be pregnant is on the previous, on the previous slide? I, I'm not sure how that's happened, but yes. Um, yeah, I don't think I've got any in the chart. Um. Mhm. Yeah. So we've got people going down the route of ok, history presenting complaint. We're gonna talk about Socrates associated symptoms. We've got diarrhea, vomiting also asking a bit of a sexual history. Um, so are they sexually active, uh, any chance they could be pregnant? Um, sexual history date of the last period. Yep. Um, bowel symptoms. Yeah, certainly. Now think again your, your structure in this history, you're asking this? Yeah, exactly. So, so far we've talked through basically history presenting complaint. What else do we wanna ask? So, once we've outlined whatever the pathology is where we go from there. Yeah. So you've got some people putting in some red flags here. Um, so weight loss back pain, ideas concerns expectations. Remember, I think I said to you guys before ideas concerns expectations is a chunk of marks. If you think that you want to either run out of time or forget to ask ideas, concerns and expectations at the end. Put it at the beginning. Do your history of presenting complaint so that you go through it, you say, oh, you've got tummy pain. They go oh yes. Um I've got tummy pain and PV, bleeding and you go, ok. What do you think it is? What are you worried about? And what's the best thing that I could do for you today? Do you see how that links on really nicely with history? Presenting complaint? And then you can go into? Ok, so I'm just gonna ask a few other questions about your past medical history. Then you do past medical history, drug history, family history, social history, smoke. Yeah. Social history, smoking, alcohol, job, home drugs. Yep. Night sweats. Yeah. Big red flags. Allergies. Any lumps. Yep. Um I'm gonna ask, is there anything else? But I'm really asking myself that question. Is there anything else that we're missing? Uh I'm not seeing anything on the other chat. So I think we're, I don't think I'm missing anything. Ok, brilliant. So, what I have here is just like a little checklist. This is not really for me right now. This is for you if you wanna use this later on. But what did we talk through? We talked about the presenting complaint, I've put here, make sure that you always ask an open question because it's always worth a mark, right? If you don't do open questions, you're not gonna get the mark for having open questions. So you say so what's brought you in today? Um uh Systems Review. So we had people asking about the urine nausea, vomiting, bowels, weight loss, that sort of thing. Um What I tend to do for assistance review is do a proper top to tail. So I start with all the pathologies that I can have top to bottom that I could be worried about things that I don't want to miss. So I tend to do, I did to do any headaches, any hearing loss, vision problems, dizziness sort of like in the head. Um, any breathing problems, cough, chest pain, any tummy pain, any problems with the bowel or bladder and then any weakness or tingling in the hands and feet. That's what I describe as the full human body uh, if that's accurate, I sure somebody who's doing anatomy would disagree this more. Um, I've said specifically here. B and, but I've done that specifically because this was a Abdo history. Um, we've got Socrates here as well. People did that. I'm not, I'm not actually sure if anyone did actually say past medical history. Oh M HS. Yeah. Past medical history. Surgical history. Why? Surgical history? Because this is a tummy history. It's always useful to ask, but you may wanna make sure that you explicitly ask it in a gi one drug histories, we wanna know both what they're taking and then their allergies is like to like smoosh in that people don't take it. So just make sure that you ask like, have you take, do you take your drugs? Do you not are any of your drugs that you don't take any family history? You don't need to go into massive detail with this because the majority of people don't have a family history and even if they do, it's not relevant. Um And again, specifically in this case, we asked about social history, we asked about pregnancy, smoking, alcohol occupation. I'm not sure if we mentioned diet. I've also put travel history here because what we have, if you've got vomiting, like people asked about, we want to start thinking about infectious causes, ideas, concerns expectations and summarize this is a four minute history. Summarizing is challenging in four minutes. But if you can try and summarize back to your patient just as you go through. So, a really nice place to do it is in your presenting complaint where patient says, yeah, ABDO pain PV, bleeding. And you say, OK, so just to summarize, you've had a five day history of worsening tummy pain. And have you also noted some, some blood down below? Is that right? And they all say yes or they'll say no, it's six days and you go 06 days, OK? And then you say, like I said, any idea what it can be and then you see how it's just linking, you can summarize at the end. It's always a good idea. It helps structure stuff in your head, but you do get points for summarizing. So just make sure you do that. So I think really we covered most of it here. We didn't ask about compliance. I'm not sure we asked about family history. OK. So the a look so um I could have answered your questions step by step and actually answered what you said. But that's kind of cringe this is the outline of all of the history if you were the perfect student and you answered everything right? You asked everything. This is what we find out. 19 year old female abdo pain generally unworn yesterday, central abdominal pain started off lunch worsened, started in the middle. Now more over the right hip, started after eating lunch. Suddenly crampy and sharp. No radiation vomited once this morning. It's worsening. No exacerbating or alleviating factors. Severity eight out of 10, otherwise fine plus medical history of asthma. No surgery. It's salbutamol microgyne, no drug allergies, no family history of any tummy problems. No travel history smoked five cigarettes, social drinking around eight units. No drug use. Psychology student, unsure if could be pregnant. Cos they're currently on the pill. Ideas concern that expectation had suspicious meat two days ago, maybe food poisoning, pain's really bad. It's not getting better, need something for the pain. So, um, so what you'd then do after you've been presented with this history is you'd get your first question. So your first question is summarize your findings so close your eyes. Ignore me for a second. You can type it. Uh I in the chat or anything if you want just in your head, how would you summarize that history? I'll go back to the history if you want actually, you know what I would try and remember it. How would you present it? I'm not sure how many people are actually doing that, but hopefully that's a good bit of practice to do. I'll give you a bit more prep to actually summarize the next one. I appreciate that. You've not taken this history. So it's harder to do it. Just like, how will I do that? You've not got long. It's like a minute, two minutes. You just want to make sure that you're summarizing the important positives, relevant negatives. I would always end my summary with my differential diagnoses. But if you don't, the next question will be, what are your, what are your top differentials? So I've changed that onto the the mentee slide you can put on there, you can put in the chat. What are your top three differentials for this patient? 19 year old female, central abdominal pain, crampy suddenly came on whilst eating. Um one episode of vomiting, nothing making it better. Nothing making it worse. Um, eight out of 10. Now. More over the right hip. No. Oh, asthma, salbutamol smoker of five cigarettes, suspicious meat. Maybe I should keep this off the screen. I know that I definitely would be annoyed that I could see other people's answers. I won't do that for the next one. If you wanna put it in the chart on me. B please do. Mhm. Ok. So again, if you're, if you're thinking about it at home, even if you're not interacting on the screen, just more importantly, what would you say with this history? Right. So it seems like people are coming up with fairly similar things, right? A lot of people have said appendicitis. A lot of people have said gastroenteritis. We've got ectopic pregnancies on there a few times. UTI S on there a few times. Constipation, cystitis pregnancy rule out sepsis. Somebody listened to my, my wisdom back in January roll out sepsis. Always rollout sepsis. Um, am I being really silly. What's T SS two toxic shock? Sorry. Yeah. Oh, wait, no. Is that how you'd write that? Staphylococcic toxic? Would I write the other if that's what that is? Like, please do, please do, tell me what T SS is. I think I just write it differently. It might be something completely different. That would be re embarrassing torsion. Yep. So important thing being if, what you said, like you can sort of say, like, I mean, I know what I think it is in this case and I can see that some people have not got what I think that it is. Right. My biggest concern preparing for is, is that I would take a history and then I would come up with my differential diagnosis and it would not be what it was. Right. So I'm gonna say what I think it is, but it's fine if you've not said what it is because none of the things on here are what I would describe it. Oh, toxic shock, I think. How would I write that? I guess it's just I would write ST S but T SS makes sense, doesn't it makes way more sense like Staphylococcic anyway. Um But yes, that's an entirely reasonable differential. No, nothing on there do I think is completely unreasonable. I think there are some things that point away from some which is fine because I think in, if you were actually gonna give you differentials, you would do it as sort of this person said here where you'd say, ok, my top differential is gastroenteritis. Um, my second differential is toxic shock syndrome. Uh, however, she doesn't have a history of, I don't know, not taking tampons out. Right. Doesn't rule it out completely. But like you sort of justify why you've said one of them is your main diagnosis, right? Um, yeah, so none of these are unreasonable and if you do get it wrong, you will lose marks for that, right? That's fine. They will tell you for the management question, what the diagnosis is. So let's say I say that the answer to this question is uh spinal metastasis. That's the most unreasonable thing I can think of for abdo pain, spinal Mets and they go OK, I'm gonna do you marks for that because that's not a reasonable differential diagnosis, but it's what I put as my top one. The next thing will be given the likely diagnosis of whatever the diagnosis is, outline the management. So they won't tell me to outline the management of Spinal Mets despite that's what I've written. Yeah, P ID is also very reasonable. Ovarian cyst. Yeah. So yeah, like a bit like I was saying, if you stand outside, it's tummy pain. So it can be an abdo sort of pathology, but also it's tummy pain in somebody who has uterus and ovaries. So also it could be a Gyne issue, right? So the ones that I've put here again, doesn't mean that these ones were unreasonable. These are six. I just couldn't count of what i, of things that you could suggest. Um, appendicitis, ectopic pregnancy, cyst gastroenteritis of various portion gastric ulcer is probably the, the wildest one I did. II did, um, one of the wildest ones. Um, I think I've probably put that on there just because you've got this, this person whose pain came on after eating. Um, yeah. Yeah. Really good, um, suggestions. So, again, what investigations would you order? You do not need to type this out if you don't want to but answer the question, what investigations would you order in that patient? Say out loud, type it down whatever, what would you do? Ok. So I've given you a minute, uh, hopefully in that time if you're doing in your head or you're reading it out, you've had enough time to do it. Sorry if I'm talking over you, um, remember what we're trying to do here is rule in what we think it is or a rule out what we don't think it is. And if there's any red flags, we wanna make sure that we've coped with those. Right. Um, it's also good to make sure that you have some sort of structure when you're presenting your answers. Um, and also you may need to justify your investigations. So, just make sure that you can justify your investigations even if it's really, really generic thing. Now, I guarantee if any of you have said that out loud or done it in your head, you've said FBC is using these LF TCO B, right? Of the blood tests. Right. Now, if I specifically asked you, why are you measuring FB C in appendicitis, you may not know the answer to that question, right. The question is more likely. Why are you testing FBC in this patient? Now, hopefully, you know enough about each of the blood tests to justify why you're doing it in my mind. I'm like FBC, I'm either looking for anemia or infection, right? So in this one, it's probably gonna be raised white cells if I'm thinking this is appendicitis or uh even even if it's, I think it's something like an ectopic, right? That's what I'm thinking about there or even though it could be anemia if, if the, if you're asking about LFT S and I would just say to assess the liver or kidney function. But if you're looking for something specific, then by all means, say it, right? Um OK, so that would be my main thing. The structure that I use is bedsides, bloods, imagings, special test at the bedside is stuff that I can do at the bedside. Um Blood is all right, blood test imaging is X rays, CT S MRI S ultrasounds and special tests is anything that's like specific or a bit weird. So like there aren't very many things but things like genetic tests, I sometimes shove in there because I don't know any specifics. Um So again, I can see that some responses are coming in here if you just wanna have another go at saying your answer out loud but reframe it, bedside bloods, imaging special tests or another structure just as part. OK. I said that I think the majority of the answers on here have come up with some really reasonable things. FBC S LFT, CRP amylase urinalysis, CRP TF BCE, FBC. Yep, C RP C RP is for inflammation. Yeah, not infection, but that's just like a um And then we've got, so that's sort of the bloods. Have you got any bedside test, pregnancy test, urine dip yep, abdo exam, vital signs. Yeah, stool culture and vaginal swabs. These are bedside tests. Um Another one that you can use is B boxes. I don't know B boxes, but I think the O stands for orifices and you do like sputum cultures, vaginal swabs, that sort of stuff. Um So if you prefer that to bedside bloods, imaging do that. Um imaging. We've got ultrasound abdo x-ray. Yeah, again, nothing unreasonable on here. Um So thing that I would say that would catch me out in this scenario, what do we think it is appendicitis sort of like our, most of our main differential diagnoses. If not, we also had some people saying let's actually scooch you back, let's have a look ectopic. OK. So appendicitis ectopics seem to be our top two things. How are we gonna manage those broadly speaking? And I'm not asking for, tell me the management of it, but cos there's an investigation here that we would need to do for both of those pathologies. Yeah. So, when you've got, when you've got a surgical pathology and remember the outside the station, it says acute pathology, acute surgery. When you've got a surgical thing, clotting grope and save cross match. Is that all good? But yeah, that's pretty good. Oh, someone's coming after exam by my Yeah. Yeah, exactly. A lactate would be a good idea. Somebody mentioned, by the way at the beginning about um query sepsis, you wouldn't be amiss to say I would consider starting the sepsis six year. Um I've put some examples of what I would say, urine dipstick, pregnancy test BP and APR I didn't even put APV. But yeah, F BCU and E LFT CRP beta HCG blood cultures again because I was thinking of them plotting group and see. And then the imaging for the imaging for appendicitis is an abdominal ultrasound. Um If you've got the actual guidelines, say if you've got a thin male with obvious clinical picture of appendicitis, no imaging necessary. If you've got like a female, same, same presentation, you should do it because you rule out you're looking to rule out um uh pelvic organ pathology. So like the ovarian stuff, right? Um And then if there's a diagnostic uncertainty. Then again, you wanna go there. Y pr two things, one, you can replicate abdominal pain on pr exam with appendicitis. Um But yeah, also it's just a good idea to do it with abdominal pain. I just know it specifically for the appendix. One. Also, if it's in a kid, they often won't be able to hop on their right leg. So you can always ask if you think it's appendicitis or so abscess, that sort of thing and ask, are you able to walk normally? Does it hurt to walk? OK. I hope that answers couldn't. So these results again, ignore the screen just how would you read out and present your answer to this question, interpret these results and then answer if you want somebody savaging my maths. Gosh. Yeah. So said the year is wrong um which is check patient details on a calculator because I'm really unsure whether he is as well. OK. So hopefully that's enough time for you to have talked through those results. Remember as we go through them have a structure to do in it. Yeah, because you know that you're gonna be presented with blood test results. You know, you're gonna be presented with imaging. So you need to have a way that goes through blood test results on imaging. We don't know what blood test results are gonna come up. So the way that I will, I always do it is OK. These are the blood test results of Nina Shana, date of birth 22 03, 2003. I wanna cross reference this with my current patient to check that. It's the same. I'm also going to see if there are any previous results I compare it to. That's my introduction to all of them. It doesn't even matter if the date and the stuff does uh does match up. You don't need to, to be as on it as this person was. But if you can obviously brilliant, but just say I would check that this is the same person. See if there's anything else we can compare it to. Then my recommendation is you go down every single blood test result and you read it out as whether it is high or low and you summary statement at the end of what that means in the context and then you link it to your differential diagnosis. If you don't know which diagnosis it points towards, you can say that you don't know and you can say that I would I show these results to a senior sort of thing. Um So let's see what people have sit here, ro platelets indicative of infection platelets. I'm not seeing these platelets as raised, I might be wrong check name and age read out normal and abnormal results raise, neutrophils count case of infection. Yep, no one's actually mentioned the other abnormal result with the white blood cell. Yeah, the neutrophils are up, the white blood cells are also up. Why are they up? Probably because of the neutrophils. Yeah, but we still wouldn't rent it out. Um Brilliant. Ok. Um So the way that I would present, this would be the hemoglobin platelets, mean cell volume, lymphocytes and HCG are all normal whereas the white cells and neutrophils are raised. This represents a neutrophil predominant leukocytosis combined with the negative pregnancy test that supports my most likely differential of acute appendicitis. Remember, we went through the words for high and low. So, leukocytosis and leukopenia. Um this is high white cells. So, leukocytosis and I've described that as a neutrophil predominant one because the neutrophils are raised. But the other stuff isn't my two main differentials as you guys pointed out are probably gonna be down the route of appendicitis and ectopic pregnancy. At this point, I've got a negative pregnancy test that rules it out. That's why I've said combined with a negative pregnancy test, if you were going down the route of thinking the gastroenteritis was your primary differential diagnosis. This wouldn't help. This would this would support your diagnosis and you're very likely going to say that com like you would say, this is a neutral, predominant leukocytosis. This supports my most likely diagnosis of gastroenteritis. And from this information here that does support that neutrophils are often raised in appendicitis. Um So a neutral, predominant one is just common. Um But that's ok because that's I'm just pointing that out is that, that still supports your differentials. Um and being able to narrow down from whatever three differentials you came up with to the one is good, like I said, and if you don't know, and you can't say this supports my mote lightly differential, you can always say this doesn't seem to help me narrow down my differential list. So I would consult with a senior. OK. So given the likely diagnosis of acute appendicitis, this patient requires a cannul before they can go to surgery. Put a Cannula in the model. This is for you afterwards. This is not for now, I've put both in the learning central one for Cannulas and also the youtube video here. If I could give you bits of advice about putting in Cannulas here they are wash your hands. If you're not sure if you need to wash your hands before you do a step, do it, it's better safe than sorry, speak to the patient proper over the top. Like I'm asking you to do now over the top, talk to the plastic arm that is in front of you. So you're gonna go up and you're gonna be like, oh, hi MS Shana. I've been asked to take it, put in a Cannula today. That's just a needle that goes into your arm so that we can put some, put some medications in. Does that sound OK? Have you had one of these before? Do you have any allergies? You got any questions about what we're gonna do? Are you happy for me to put one in? Do you have a preference of which arm? And then like, as I'm preparing my stuff and I'm getting everything ready, I'll be like, oh, so mis sha are you OK with needles? It's really over the top, but it's really just demonstrating that empathy, especially if you feel like you didn't demonstrate empathy very well during the consultation, right? This is a great time to show that. And if you fail, right? If you don't get blood and you try and do it and you don't do it, there's 100% the fine, you do not need to get blood or you don't know how to get a flashback. You don't need to successfully cite the cannula to pass this part of the station, right? If you have enough time, they'll say you have enough time. Try again. If you don't have enough time, then they'll say, don't worry. And you would explain what I would do here is I would drush this wound. So I'd press it with a cotton wool and then I would put a plaster on it after a while. Then I would go and get some more equipment, rec rec recite a vein, clean that vein and then I would start again. Um Yeah, so don't worry if you don't get blood, it happens to a lot of people. OK. So here's my little summary sheet for acute appendicitis. Again, this is not for now, this is for afterwards. If you need it, use the the format to make sure that you have the absolute like what's necessary for it. I've got here buzzwords for appendicitis. Young patient central to the right iliac fossa. I said it was over the right hip anorexia is very common and often they, they do vomit but they only vomit once or twice. Um So if you've got somebody who's vomited eight times in the past eight hours, that's unlikely to be an appendicitis. These four minute histories tend to be pretty bundle. This one, I made it a little bit harder like I said about just being like generic about, oh it's over the hip, that sort of stuff. But they usually bundle like you see it and the majority of people narrowed that down very quickly to the appendicitis in the atopic pregnancy. Um I've put here both Robing and so, so a sign as well ring is where you press on the left. Iliac fossa makes pain on the right. And so a sign if you extend the hip, it hurts. That's basically what's happening with the kids hopping. So in terms of acute pathology, then what are our important acute conditions that your exam is in two weeks? What are we wanna make sure that we've definitely covered when it comes to acute stuff? I've put six on the screen. What do you guys think, what are your, what things do you think are the most important ones to cover? Just to help each other with your own revision? Just to see if some people's mentioned something that you haven't, there are no important acute conditions. You know what? Actually we shouldn't even do acute medicine. Anaphylaxis. Yeah. Yeah. Mycotic infection, appendicitis, stroke, miti a is interesting. I think you're more likely to have a stroke. But, yeah, Uh, arrhythmia called requi ok. Stemmy, heart failure, pe asthma IC O PD. Critical Lemos. Yeah. That's an interesting one. Another interesting one that I think, I don't really know why I get the vibe. You'll get a testicular torsion or an ovarian torsion. I don't know why I have that vibe but it's not come up previously. But it's one that you can, that's pretty, pretty bundle when it comes up. So perfect PD. Yeah. Pyonephritis. Oh Tors G ob AAA. Yeah. Sepsis. Oh, ectopic comma gi bleed. I was like ectopic gi bleed. Um Yeah. Acs. Yeah. Brilliant. I'm just gonna leave that up for a second in case anyone's like, oh, I haven't thought of that one. Critical I schema is probably a good, uh, good one. It's, it's not one that I would have had on my list, but you just wanna make sure that you've seen it like recently. Well, like it would be unlucky to come up, I think. But if it does does come up, I want to have seen it recently. Um, cellulitis. Oh, that's interesting. Yeah. Ok. Let's see, what, six? I put, no, I meningitis stroke, AAA, sepsis asthma. I didn't even put anaphylaxis, but I agree. It was the first one that came up. I agree. I think anaphylaxis could come up. Um, that's OK. Somebody said subarachnoid as well advanced I support. Yeah. Um, these are the six that I would do if I last minute needed to do something, I would do those six. Um Right. Again, this will all be on the thing. Um Right. Any questions about this one? You can put it in the, on that ment question, you can put it in the chart. Any questions on that station? No. OK. I'm gonna advance the slide but I'll leave that up for a second just to see. So let's move on to the second station then. So read that again in your head. Just think. How would I prep for this? What am I running through my head as I'm standing here? OK. All right. So pharmacology and therapeutics, persons diagnosed with DVT started on Warfarin. Explain what the Warfarin would entail me standing outside this station. I'm bricking it. Um That's my interpretation of it. And I'm just trying to rack my brain of everything that I could come up with with Warfarin. I've moved on to the next side on the mentee. What do you want to ask or what do you want to say in this consultation about Warfarin. What are the main points we wanna hit? It's a seven minute history. So what is their understanding requires monitoring with the Inr if you hit your head, come to the hospital, what do you know about warfarin safety net for bleeding? What does the patient know about Warfarin? What's their story so far? Yeah. Brilliant. Increased chances of bruising bleeding safety net around prone bleeds. Yeah, we started already. Any side effects. Yeah. Avoid leafy greens. Oh, in, I like that in excess side effects. I am monitoring what other medications allergies take it. Yeah. How to take it? How long? Yeah. And just in the same question here, how confident would you be on this station? Yeah, that definitely is medium. Yeah, I wouldn't feel very comfortable with this at all. Um, s obviously do test your knowledge. But the rest of the station, yeah. The rest of the stations you ask questions for seven minutes and then they ask you questions. This is, you just have to, like, produce all of this knowledge. Like, it's just a test of how much do you know about it? And I just find that I find that very intimidating. Um, semi competent was also panic. Yeah. Just the way that we do exams. Normally we don't ever have to do that, um, on the fly as well. Um, so, yeah, it's a bit of a challenge. But, yeah, it seems like a lot of people have covered really important bits. I've put a little structure for this history that I would recommend for a medication one, number one, it's just gonna be established what happened. Um So they came in with ad at. So, so I know that you, you were went to hospital recently. Tell me what happened again, open questions, brief, what happened. Um At that point, ideas, concerns and expectations in the context of medication. This is the what do you already know? Do you have any questions? Are you worried about anything? And what would you like to get out of this meeting? That's what those questions are and that's what people have said. Um And then equally current understanding, just make sure we explicitly say, what do you already know about it in terms of the medication itself? I recommend that you talk about that mechanism not in detail like you would if Marcus Coffy asked you, but like you could say it, it, it's an anticoagulant, you know, it, it's gonna make your blood thinner, right? Like explain it in like layman's terms, it doesn't matter if it's like actually physiologically correct, but functionally what does it do? And the use is what are we gonna use it for? Because often when patients have these stations, they'll have something like, oh, but my, my friend has it but they have it because they have a valve problem and you're like, yep, people will take it for different reasons. Some people have it to treat, um, a clot and some people have it to prevent a clot. So that just helps address that. Like everyone said, the side effects that you wanna talk about, talk about the common ones, talk about the dangerous ones monitoring. Obviously, this one has the big I NR one. Um, yep. And then lifestyle ones is that stuff that people was talking about in terms of, uh, as people said about C YP 450 inducers, alcohol, cranberry grapefruit juice, all of that. Um So that's the lifestyle stuff also, if you have to take it at the same time every day or take it with food and you know that put that bit in there and then ask at the end, have you got any more questions? And then lastly, you're gonna summarize that at the end, you see. So today we've talked about taking your warfarin, we've said about this, this, this, this, this all good. Um I just wanna put over here. So I put this, I wouldn't know how to pronounce that Boies. Probably not like that background, understanding concerns expectation and explanation and the summary. I just think it's quite a useful acronym if you've not got something like that and moving on, whoop. Um I'm just advertising that person to come do the teaching instead of me. So for this specific person, this is their history, 65 year old questions about warfarin pay in the left car for a day after returning from a flight, went to A&E was given warfarin discharge. But now coming in to answer the questions, cos the Ed Registrar was rubbish. Ideas were I have friends who take it. So I know that it's a blood thinner. I'm worried about how often I will need testing and they're hoping to answer four main questions. No other meds, no other allergies. Four main questions. Why? What are the risks? How often I need tests? What if I miss a dose? The questions they will be asked to like line up to ask. You are gonna be the ones you're gonna answer anyway if we follow that structure. But it just helps that if we don't know the answer to those questions that they're asking specifically, it just gives us the opportunity to demonstrate that we are an honest and safe practitioner. We say, oh, that's a really good question. I don't actually know how often you will need tests. What we can do is I can provide you a patient information leaflet. I can also check with my senior before you leave. Yeah, we've just been honest. I'm gonna give you some info and I'm gonna go get more info, right? Um OK, so summarize the consultation, I think I'm really gonna ask, I I'm not gonna ask you to do that because that's that question is silly. Um But that is the question you would be asked here. I'm not gonna get you guys to do it just because like I said, you've not taken that history. So it's not gonna be in your mind like it will be in the exam. But you're very welcome to practice that. Have a go with that. I hand this to you in the exam. Interpret the CT hit, don't judge the year if it's wrong. OK. That's coming up to a minute now. So hopefully people are sort of wrapping up ct heads are hard because unlike chest X rays, which you probably looked at a bajillion times and have a very nice structure for, you don't really have that much of a structure for this. You can do a structure for it. It's just that the majority of it is fuzzy gray mush. So it's a lot easier to just jump into. I can see, I can see this pathology. Just make sure that when you are talking through it, you tell me what's normal as well. So I'm gonna wait a few minutes just in case anybody else wants to write an answer to what they think this is. And remember in real life, this is a lot easier to see. Like I know that people are trying to figure out if there's a midline shift or not in real life, you scroll up and down and you can physically see this like that. It's a lot, it's a, it's a lot easier to see. OK. All right. So I'm gonna scoot this over and let's have a look at what people have said. All right, we have midline shift to the right uh sorry, rin line shift with the right sided convex hypertense area, right sided, soft tissue swelling. I think this is the same person as well. Subarach, check name and date of birth, epidural hematoma on the right hand side of the patient's head with associated soft tissue swelling and hematoma, no fracture, some midline shift to the left. So a circle effacement blood, acute bleed in the right frontal lobe, limited to suture lines, consistent with an E DH no skull fractures, soft sw right. So that's what people have put here. Does anyone want to agree or disagree with any of these? Yeah, I agree. I would si would say that um I just thought that was quite funny like no one's anyway. Yeah. So you can start off by saying this is act head of Bob mcallister seventh of the 6th, 1959. I would cross reference this with the patient details and also see if there's a previous ct to compare it to extradural. I'm assuming that's in response to the subarach, epidural and extradural, the same fracture. Yeah. So yeah, I wanna put what I would say for this. I think a lot of these answers were very good. It's not very complicated. You're very, you're right like um there is so face, I'm not sure I would, I'd say that in an is, but like you're entirely right. I just don't have the brain power to say that in an is um yeah. Um And it seems like you're using a a structure here as well of going through brain blood and then soft tissues which again just structuring your answer is just always good. Um So let's have a look said this axial image oh covering with which angle it is actually it shows a fracture of the right temporal bone. This here you see that interruption in the cortex here for the people who said no fracture, were they, this fracture itself goes through the frontal through the temporal bone. And so like if you look at it and you scroll up and down through it, it sort of goes like here downwards, we can't see that um because it's just one picture. Um and it's OK to miss fractures as well, they're hard to see. Um But what we're looking for when we're seeing a fracture is you're just looking for, is there any interruption in the normal continuity of this bone? Now, CT heads are nice for this because the bone is really nice and white. So we go all the way around and oh it just goes in a little bit here. So I'd say even if I'm looking at that and I don't know if there is a fracture, I'd say there's, there's a potential fracture on the right hand side and it's OK if you don't know whether it's the temporal bone or the frontal bone or whatever bone. Um because again, we can't really see at what point we're here. I know that that's the temporal bone cos I've seen where this is in the head, right? Um Yeah. So there's underlying extradural hemorrhage or epidural hemorrhage here, an overlying soft tissue injury there is midline shift. So you see how midline should be going straight here but oh oops, oh you're gonna go back there we go. Should be going straight through here. But it's going like angle. We can't see the ventricles. If you see the ventricles, it makes it really obvious, but we can't see that on this, but you can see that's going whoop, no evidence of other infarcts. So basically the rest of this looks like normal mush. No other bleeds. This represents a significant intracranial bleed in a patient taking Warfarin which is emergency, which is just linking it back to that type. Does anyone have? No, no worries anyone who got sorry. That's in response to one of that. That seemed like it came out of nowhere. Does anybody want to add anything else? Any questions about the CT whilst we're on it? Are we all good if you're unsure of whether it is an extradural, subdural, intracerebral or subarachnoid, say intracranial? All right, intracranial bleed or an intracranial hepatoma is blood pooling outside of the brain where it shouldn't be. And then the other ones are telling me specifically where that blood is. So if you don't know specifically where that blood is, is it intracranial bleed? Yeah. OK. His I nr is found to be 9.2. So remember this is a separate patient to the guy that we had at the beginning, this separate guy with the brain bleed. I nr is found to be 9.2. What is your short term management of this patient? Again? Say it out loud to me. What would you say? OK, so hopefully you've had enough time to have a think about what you might say, short term management. There's two things I wanna be thinking in this scenario is one. What is short term management? Two is what is the station? The station itself is a pharmacology station. So this is likely to be talking about the medication doesn't mean that you're not gonna do other stuff, but like we're just gonna make sure that we address the Warfarin specifically. Now immediate management is what you're doing now, a two E approach, right? And then the short term management is OK in the next eight hours. And then the long term management is when this person's back in the community. What's happening? How is this person going to surgery like in the next couple of hours? Maybe not, hopefully but maybe not. That's, that's not even, that's not me anyway. Um uh Yeah, so that's what we're thinking when it says immediate short term, long term what people have said is major bleeding needs warfarin reversal with IV. Vitamin K and F FP. It we approach senior help stop Warfarin give Vitamin K and F the IV infusion prothrombin complex stop the anticoagulants ma CG and Ir Vit L antagonist higher dose. I'm assuming this is Vitamin K I'm not really sure what you mean by a higher dose. I think the dose probably needs to be down titrated. Um Consult on the hematology and stroke team. Yeah. Warfarin basic observation signs of hypervolemic shock need for transfusions. Major hemorrhage. Yeah. OK. F FP. Check in R coag screen. Yeah. Stop Warfarin. Start IV IV. Vitamin K eight ef Yeah. Neurosurgery. Stop Warfarin give Vitamin K and Prothro. Yeah or cave night. Are they? It's a hard question, right? We have a picture that shows blunt, there's no way for actively bleeding but this will always be IV because this counts as major because it's intracranial. So either if it's intracranial or if it's like life threatening artery spurting bleeding, it's always gonna be IV, that's a good thing to think about, see what I've put. Oh yeah. So I've tried to do this as like a to like to structure it about what would happen in my, in the short term in my mind. So follow an a three approach to ensure the patient is stable. Get early involvement of a senior, including my own senior as well as SBAR approach to hand over to the nearest surgeons. The answer is what is my short term management of this patient as a as 1/4 year medical student? This right. So we have to just make sure that we say it regarding the warfarin, follow the guidelines for high nr and major bleeding. This would involve stopping the warfarin. So yep, stop the warfarin. Like you said, IV Vit K pre complex concentrate to reverse the anti. When you've got major bleedings, we have to make sure that the blood pressure's stable and we give uh some saline also consider blood products. Basically, when you lose blood, you wanna replace it with blood, but you also want to have, this is separate. You want, you want to consider a permissive hypotension because if this person has like a, a hole and they're bleeding through that hole and I pump a whole bunch of blood in to them, that blood's gonna come out of that hole still, right? And I'm gonna make the midline shift worse and then the person's coning and they're not, they did. So you might consider that's why we're looking at BP um may require IV Mannitol. So I'm not sure if anyone's said about Mannitol. Um But this is because we've got that midline shift. Um And so we wanna decrease intracranial pressure as much as possible. This is gonna basically like suck out all the CSF as well as IV boards B antibiotics. We just got a fracture also got a fracture and a brain bleed, make sure he's got analgesia moving forwards. He's likely to receive a cran after him. You can give anti convulsants, but we tend not to give them sorry, someone asked that, but we tend not to give them prophylactically. But if they're high risk for it, then yeah, if they have a, a history of seizures or if they have seized, then yes, hopefully, like I appreciate that I have had time in a calm mind to write this down. This is really nicely and well structured and you may be sitting there thinking, well, I couldn't do that if I were sitting in noisy trying to produce that. We don't need to hit all of these points, but we need to hit some of them and your management plan will not include everything I didn't even mention anticonvulsants, but someone's very rightly pointed out that you can give anticonvulsants raised ICP in brain beats, right? So just, just be clear that one, you will not be able to say all of this, that's fine. Just try and make sure that you're hitting the main points and the main points in my mind here is he's got an I nr of 9.2 with a major intracranial hemorrhage. Y you have to stop the warfarin, right? So making sure that we hang on that the majority of patients are gonna need analgesia that always just gets you points. If you say it um and yeah, hitting as many of the points as you can just is just always good. Um But try and have a structure that first sentence. It's pretty, that first paragraph over here, pretty solid. You can bring that up in the majority, right? For an A ABC approach to each other, the patient is stable. I don't know anything about this patient. I just know they're on Warfarin, they hit their head and I've seen a CT. So are they stable? And then most of them, we're gonna get early involvement of the senior. And then you may need to refer, this is fairly replicable. We can just put that at any time and then the rest of it is just trying to hit the key points of the pathology. OK. So that's the Pharmacology station. This is my summary for an intracranial hemorrhage. Again, this will all be up there. You don't need to take a picture of it. We can, but again, buzzwords, I just put about the E DH having that lucid interval and the sa H having that thunderclap headache, subdural hemorrhages. You often have uh if they're chronic, you'll have just like that confusion, decreased consciousness and coma and it will be over like a long period of time. That's also what happens in acute but not over a long period of time. This is the be for Warfarin same thing. This would be useful to make for those, for the medications that are worth covering. Um And I've just summarized Warfarin here. Um, counseling and prescribing consultations. Geeky medics has a list of, they have one for Warfarin, for example, they have one for a lot of other meds too. So if you wanna know how to structure it or what information to put on a similar sheet to this, that's where I would look. So, what do we think of the important medications that again, exams are in two weeks? What other things? I'm just gonna make sure that I brush up on. What are my important medications to cover? What do you guys think? Are you asking that anti convulsant question, anticonvulsant question again or was that an accident? So again, just to reiterate in case the person is asking again because they missed it. Um We don't, we don't always use prophylactic anticonvulsants in brain bleeds. There's a little bit of controversy over the use about whether they should be used for all patients. So basically, we use them in patients who are high risk for seizures. Ie they've had seizures in the past or if they've had seizures like in front of you. And now um so based on the patient, you would not be amiss for bringing it up. So we've got Doac statins, methotrexate, contraception, bisphosphonates, scia, amiodarone ace inhibitors. Yeah, it's very likely to be either the common one or a zoning out or a scary one. Warfarin is a scary one because it can go wrong very quickly. Ace inhibitors are common ones. They're not really scary. Um, yep. Nsaids. Um, I could also, I could see them similar to what someone says here about migraine meds. I could see them giving you a medication, overuse headache. Um, which is not, it's not a medication history in terms of, I need to go away and revise medications, but it would be a pharmacology station of a patient comes in because of side effects of medications because they're taking too many. Um, yeah, lithium antiepileptic carbimazole. Yeah. Yeah. Antipsychotics are a good one as well. So I'll just make this bigger in case anyone wants to take a picture of what other, other pe or it doesn't there in case you wanna take a picture of what other people are thinking as well. Ok. I only put four for this one. I went for Warfarin Statin Co CPS inhalers. Remember is that inhaler advice and technique is a skill that you have to learn. And I feel like people often forget that and don't revise it. They tend to give you the inhaler. The inhaler has the instructions inside the box. If push comes to shove and you're asked to demonstrate how to use an inhaler, read the instructions, right? I would love that everyone goes away and learns how to use it brilliantly, but I would prefer that if you, if you're stuck and you're like, I don't know how to do this that you're able to do it in the exam. So just have a look at inhaler techniques. There's two types of inhalers that are on learning central that they talk through. Those are gonna be the ones that you need to know. All right. Mm. All right. Any questions about that station? It seems like people are asking questions of Google. But if you want to ask her, I think, how do they decide the stations? I think what would make you cry the most? Um No. Um, so they, they, they follow the same thing, um, that, that I'm suggesting you do here is they look at common and important. There's that big long list of conditions that you need to know. At the end of F one, you can look that up if you want big long list of, um, conditions that you need to know. Um, and, uh, the MLA one obviously has one as well. Big long list. Um, look at those and then what I would do is you could just go through and highlight the common ones like what's likely to come up and then the important ones, what's life threatening? The common ones are gonna be your chronic ones that will come up in the regular ones that will be things like co PD asthma, heart failure, other things, something that you can survive, be comfortable enough and come in. Um, yep. And then you've also got the acute stuff, the acute stuff won't be people like actual patients or anything but your acute stuff is just gonna be those life threatening ones. That's the ones that we put a list of earlier things like anaphylaxis. And so, yeah, all of them will just be common and important. What do I think? Testicular to? I don't know. I just get a vibe. I don't, I honestly don't really know. Um, but I think, I think they're sort of starting to come around to the fact that they teach sexual health poorly. Right. I think that we, they, we don't really learn that much about Gyne pathology. Full stop even in your W CF block. Right. And they're doing the same for the fact that you don't really get taught a lot about Euro. Like, we don't get taught how to do like a testicular exam. And that seems to be something that the med school are re like, realizing I do a lot of med med ed stuff. So that seems to be something that they're sort of coming around to. And so my thought would be, is that like, I can imagine that happening is it's common and it's like important, it's organ threatening. So I feel like it ticks the boxes for something that's common. Something that's important. It wouldn't be an exam by any means, it would be a history. Um, but I think a testicular torsion could come up as a key one. Will it be different? Because this is an MLA is, they've not said that they're changing any of the, any of the structure for it. Um And the MLA content list is the same as the fy one content list. Um So I wouldn't expect it. And the, the med school is still saying that same stuff of common, important things. The list MLA has a list of important conditions and then there's also one for foundation year doctors. Uh When I put up another thing, I can find it and put it in the chat for what list of conditions I'm talking about. The list of fy one conditions is long and you probably won't see all of them on your an F one either. Um, but yeah, hopefully that answers some of your questions. Do feel free to continue to put things in, read that and I'll find the lists. Ok. So hopefully we stood outside, we've read that for a few minutes and again, we've done that same thing of, ok, who's in front of me? And what am I thinking that it is? It's a 12 year old boy worsening cough, parents parking the car and said it's ok for him to talk to you whilst they're on the way. If you came to the pediatrics one, that we did a while ago, I hopefully, you know, that this sort of thing is fairly common in pediatric stations. The parents won't be there. Um, if it's a baby, it will just be with the parents and you'll be learning to take a collateral history. Um But it's likely that it will be, they have like this like group of like 12 to like 14 year old actors. Um So it's likely that will be one of those for your kids. One um one more thing. So we want, we know that it's OK to talk to him, but you wanna make sure that you're reiterating that we're getting consent. OK. Um All right. So I've put that MLA condition list in the chat by the way. Um So station three, what do we want to ask this patient? What are they called? Cough? Yup. Are typical Socrates questions. Got a cough. Yeah. When did it start? How long for medical history? Yeah. Anything about the fact that the Oh Im Si thought it was an L Yeah, immunizations, vaccination history. Yep. Any contacts. Anything about the fact that they're a kid? Yep. Travel. Yeah. Question like this like they will say no, but your question like this is like when I say like you have to talk to the arm and be like, oh needles suck, don't they? OK. Now deep breath in and you're like just acting with it, they are gonna say no because there is no parent that's gonna come in, right? Um But just making sure that you've got proper consent because even if the parents have said yes, they might not bringing anything up. Oh like Oh, yeah. Coughing something up. Um, any pain. Had your vaccination school? Yeah. Birth growth, immunization, development school. Yeah. So, social history, we wanna really make safe, that, make sure that they feel safe. They wanna make sure that they feel safe at home. Safe at school. Birth and developmental history. Yes. In a younger child. For sure. Especially if you're talking to a parent less. So, in, in teenagers, especially if we were just told them the teenagers, they might not know it. But like you can always ask a couple of probing questions and if it seems like the actor has that script then push further and if it doesn't seem like it, then don't. Yeah. Shortness of breath. Right. Yeah. Let's move and just see what I've written just to make sure if I've got anything yet. So like I said, proper consent, this patient. So I would say hi child may 7 and one of the medical students, I've been asked to have a bit of a chat with you today. Is that all right? I know that your parents are still out parking the car. Are you ok for me to talk to you whilst they're out or do you want to wait until they get here? Presenting to complain again to your open questions. Socrates B Bladder Systems review. Um all this stuff, allergies, compliance, um family history, if they know it. Uh we talked about in that pediatrics, one doing um head home life, education activities, diet for kids. Um, the diet is kind of less important when it comes to teenagers. But like, if you're talking about a baby, we wanna know what they're having, they feel safe at home. How's school getting on? Ok. What do they do for fun, smoking and alcohol if you think it's appropriate, I guess some of the expectations to summarize. Ok. So this is the actual history that we have 12 year old boy worsening cough always has a cough worsened and became productive in the past two weeks. It's clear mucus with no blood feels wheezy. He's had several chest infections like this in the past. Noticed some weight loss recently and some tummy pain. No past medical history. No surgical history, no drug history, no allergies, family history, none of respiratory issues. Born in Bulgaria, moved here when two lives at home with parents. No concerns doing work at school, feels supported, loves rugby, no smoking, no alcohol thinks it's another chest infection concerned because he just doesn't know why he gets so many and expectations. He gets the normal antibiotics. Again. You would be asked to summarize this encounter. But I'm gonna ask you, what are your differentials? We need three top three differentials from this history. This one's a bit of a tough one here, but I'd rather you see the tough one like, like it's not like it's a super random out of the park diagnosis, but it's presented in a bit of a, it an unusual way, but I'd rather you saw an unusual one now so that, you know, to think about it. Remember as well, they don't ask you for three. They ask you for what are your differential diagnoses? I just recommend doing three. And so I would always structure as my top differential is X. However, another potential diagnosis could be why, but I think this is unlikely due to blah blah blah. Another diagnosis could be blah blah blah, but it's unlikely to, to blah blah, blah. Can you tell like what people say, cystic fibrosis, TB, bronchitis, bronchiolitis, bronchiectasis, chest infection, lower respiratory tract infection, TB asthma TB, cystic fibrosis, pneumonia, leukemia, asthma, exacerbation, bronchiectasis, asthma, asthma TB pneumonia, CF TB, pneumonia, CF asthma cancer, CFDA type one diabetes, asthma. Yeah. So type one diabetes and with a DK A, do you know why? Despite this being a chest history, why? That is a reason reasonable diagnosis because it is, it's not the most obvious diagnosis here and I'm not sure that they would give it like and this would be the primary presenting complaint for A DK A. But yeah, ABDO pain, weight loss on the background of infection. This is like in kids DK presents with ABDO pain like that's the like the main thing that they come in with. So weight loss is pointing towards the DK A no, sorry. ABDO pain is pointing towards the DK A weight loss is pointing towards the diabetes and the cough has set off the DK A based on previously grumbling type one. So, yes, I think the DK and type one diabetes could be a very reasonable differential. That's why I would, that's why I would justify it. Um, but like I said, I'm, I'm not sure it's the most obvious one that we're going for. But, yeah, certainly. So, a lot of people coming up with very similar things. Asthma's on her quite a few times. Pneumonias on here. C FS on here. Yeah. Ok. Move, go on to the next one again. On top three differentials. This is what I put. So you have pneumonia, asthma, Gould bronchiectasis, bronchitis. I don't know. I've put gold on him. Yeah. So somebody said it can cause a cough. Yeah. Go can cause a cough and also they've got abdo pain. So could be a go, like, picture, right. What investigations do we wanna do then again, have a, like, read it out loud practice. How would you structure it? And if you are presenting it and you're practicing doing it, I would anticipate spending 30 seconds to a minute on my investigations. So, if you wanna practice when you're doing other cases, that's what I'd be aiming for. And it's challenging because, you know, you're trying to rule in your, like, you know what your main differential diagnosis is. You, you all likely will have different main differentials, right. But, you know, what your main one is. So you want to make sure that you have evidence for that, but you also wanna make sure you're ruling out your red flag stuff. Ok. So let's have a look what people have written bedside resp exam, cardiovascular exam, bedside s nasal swab. Yeah, because we've got a lot of FP CE L FTC RP maybe a VBG imaging with a chest, chest X ray. Bedside Arbs bloods, FB, CCR pu and et glucose, HBA1C. Sputum culture. Yeah. Oh, there we go. B box. Bedside bloods orifices is X for X ray. And then s I'm not sure what S is for but ketones. Yeah, that's what B box is every month. That's what I'm pointing that out. Breast exam. ABDO examination. Sputum sample. Yeah. Sputum samples is a good day. We've got Sputum. Can anyone give me an idea about when you'd wanna do an ABG? I think ABG is a really like commonly missed one by med students. So just like in your head, just get like or write it down here. Like when would you do an ABG on a patient? Broncho Peril? What was your two week plan be now? I Yeah, so I'm thinking an ABG in an acute ill well, patient with a respiratory issue because if I've got an acutely unwell patient with no respiratory issue, what am I gonna do instead? A VG? Yeah, exactly. Um So yeah, an acutely unwell patient with a respiratory problem ABG acutely unwell problem patient with no problem. I'm gonna go with the V BGI will answer this question, but I think I'll probably smoosh it to the question section if that's ok because I think there is a good question but I have a waff answer to it. Um um Yeah, brilliant. So I think these are all really good um suggestions. Again, it will be dependent on what you think the main diagnosis is. I've tailored it to what I think the main diagnosis is here because I wrote the case. Um But yeah, so let's have a little s little look at what I've written. Bedside observations, including oxygen and respiratory observations do include these things. But because it's a respiratory thing, I've just highlighted that cos that's what I would say in an exam. Sputum culture and spirometry. So again, sputum culture, they've got a cough spirometry. I'm trying to figure out is this obstructive, this restrictive lung disease FBC is using his L FTC RP. Anyone know why I've done Amylase? I've also put a blood glucose on here. And if you said DKA is one of the things I would expect a blood glucose to be on that. So it could be pancreatitis. Does that really line up with this presentation there? We've got abdo pain like it could be, I put it on there because of the cystic fibrosis. Yeah. So um which often ends up with pancreas issues. I it might be pancreatitis, but I don't, maybe I'm, I'm judging that too harshly because it probably is inflammation of the pancreas at some point. Um, I did chest X ray again. We've just got dodgy chest. Um, and then special test. I've put the two things here for cystic fibrosis. Ok. Sweat, chloride and genetic testing. Um, again, uh, other people have put just slightly different things and stuff. This is all entirely fine and just make sure that it lines up with your main diagnosis. Yeah. Point towards that and rule out the dangerous stuff, right? Nice. Um OK, we've got a chest X ray interpret that chest X ray, read it out loud. What would you say? OK, so hopefully people are wrapping up their expiration again, 30 seconds to a minute if you can. Um again, we just wanna work through it systematically and the systematic stuff, especially when it's a chest X ray because we have really clear, obvious things that we can do with chest X rays. That's nice like the ABCD E stuff. Um It's good to do it and it's also good to do the exposure stuff and talk about the quality of the image just because as you're talking them through cos you'll have a script for them that you can just come out with. You couldn't be looking for the thing that you think you're missing, right? Or, or the, or the pathology, right? Cos some X rays are hard to see. Um and they're stressful. Um So what I would say is this is a chest X ray of Lee Davies third of the 12th, 2012. I cross reference with, with my patient details and check to see if there's a previous X ray and then I go through what I use, right? So for rotation, inspiration, projection um and exposure. So rotation is just is the spine between the clavicles as this vertebra body between those two, which is yeah, inspiration is, can you see, you should be able to see 5 to 6 anterior ribs. Now, I'm not gonna count them, but that's more than, more than enough. Um You can count them by all means. Um But this is a well exposed image. You should also be able to see the costophrenic angles which I know that if you've got blunting of them, then you won't be able to see them. But you should see where they should be if you feel like you can't see them, but there's no effusion like it's just like smooshed. That's probably um poor inspiration. We wanna be able to describe whether it's AP or PA this is a real challenge basically ap um because of the way that they do it. So AP is for usually we use it for elderly patients who can't really stand up. So they sit down in the chair and their arms will be at their side, which means that when we take that picture, the clavicles. No, the scapula are in the way of the, the fields. So you will see scapular scapular. In this case, the person's put their arms forwards and their scapula have moved up and around like they do when you move your forwards. So they're standing up and they're doing this normal. So this is APA one because the, the scapula aren't over it. Um I'm hoping that people have seen what I'm talking about in terms of P AP. Um If not, uh just get a little picture to show you, this is just a random Google search. But you see this image here, you see how AP you can see really clearly. You've got that scapular in the way. Whereas here, this is what we're looking at here. The scapular is pulled out of the way. So you can't really see it. I hope that's oh, did I just get rid of the? No, I didn't this year. OK. I hope that helps. Um So let's see what people have said. Confirm demographics, right? Minimal rotation good. And it's pa one good exposure, airway, central and patent with the carina visible whoop, whoop there, no pleural margins, oh pleural margin abnormalities, no consolidation, no cardiomegaly, sharp costophrenic angles, gastric bubble, no pneumoperitoneum. There's one thing that I'd probably say, oh, I'll go back for it. Let's see, check, patient name and date of birth time and date a scan, adequate exposure, normal cardiac shadow, normal, high local chest normal diaphragm out, no fractures, central, no soft tissues. Yes. Excellent. Um, ok, if anyone else wants me to read through what they've written, I'm very happy to do that, but not. Yeah. Um, so what's wrong with this? What's wrong with this chest X ray? What is it showing here or in the chip? This patient has query CF, query, asthma, query, bronchitis, query and pneumonia. Yeah. There's nothing wrong with this chest X ray. This is a no more. Um Yeah, exactly. If you're at a point of thinking, I have no bloody clue what is wrong with this chest X ray. Take a bit like take up on it and say this, this appears to be a normal chest X ray. If you are not confident in saying this is a normal chest X ray, co say this appears to be a normal chest X ray to me, but I will check with a senior first because you wouldn't sign off an x-ray that you didn't understand, right. So just say that but yeah, you're entirely right. This is a normal chest X ray, but there is not a single person. I don't think in the audience who's going is normal without going, is it normal? Because that's how everyone's gonna be? Yeah. Um So yeah, just go through that systematic approach. Tell me what is not there and if nothing is there, it's fine, which is what everyone's done. Yeah. Um So I put my version of the interpretation. This is AP HSX ray image for Lee Davies. The film is not rotated, it is well exposed, there is good and spiritual effort. The lung fields are broadly clear with no ex I use broadly. By the way, when I'm not entirely sure like this stuff here, the higher is normal but it always looks like consolidation to me. So I say broadly as my like cover of things, it's broadly clear but with no consolidation, no pneumothorax, cardiac shadow is normal. It's not enlarged, diaphragm is normal. No effusion, no free air gastric bubbles present in the left upper quadrant, no evidence of fractures, but there are uninfused growth plates. Yeah, and the proximal humerus bilaterally. There are no two pacemakers or let's this is a normal chest X ray. And I've said what was diagnosed with cystic fibrosis? That's my main one is the diagnosis in this case. Um But um but yeah, are we happy with the growth plates? These aren't fractures but we should mention them. Ok. Is everyone happy with this interpretation? Does anyone want to point out or explain anything on this? I feel so sad about the person that I might say it's not normal with a sad face. Yeah, it's normal. OK. Again, please do feel free to just put more questions in as you need them, right? What next? Given the likely diagnosis of cystic fibrosis? So again, even if you've said this is pneumonia with that clear directly. Um Then they're gonna tell you how do you manage cystic fibrosis? So call them. Imagine you're in an, how would you manage this patient? Ok. So I'm hoping that's given enough time for people to sort of talk through again in terms of how much time would you have? Probably about two minutes? I think you might struggle to talk for two minutes, but about two minutes. Um It's a really good idea to try and structure your answer. You can structure your answer into lots of different things. Um You can do, you can say in terms of short term management, then long term management, you can say conservative medical surgical. Um but like it's just a good idea to just give some sort of structure and say like, oh, I'm gonna talk about this in terms of long and short term management because then even if you don't get to doing the the long term management, then you've told me that you would have done it. And that just gives me a nice structure to follow. People. Put some brilliant answers here. So conservative, explain the diagnosis to a patient with and family weight and height check should show no following of growth, diet and physio to help your mucus. See a special team MDT. They love you talking about the MDT pancreatic enzyme supplementation. Perfect. Any approach and refer to senior uh refer to a rescue team and endocrine uh patient education. Yeah. Oxygen therapy if needed. Respi physio, medical vaccinations up to date include PCP and flu. Yeah. Brilliant. I don't think I've even included that. But yes, definitely. Also flu for your, um, heart failure. Patients too treat underlying infections. Advise patients to minimize contact with other CF patients. Yep. Patient education. Chest physio, advise on cystic fibrosis and distancing. Support groups. Refer to specialists. Creon, I don't know what Trita and Creo are. What medications are these. I'm not saying they're wrong. I just don't know. Dietician involvement. Yep. Referred to support groups and online research is genetic counseling. Yeah, I'm curious about these two meds. Are these just like really widely known things and I'm just like, oh, are these um ct fr regulators like the actual specific medications? I actually maybe do not have buddies. But yeah, I'm gonna wait to see if anyone can tell me like, well, its, yeah, prophylaxy antibodies. Yeah. Um but I'll move out of the way and I'll do this whilst I, I'm curious, I said I will split my answer into short, long term management. In the short term. I use a two E approach to sure the patients are acutely unwell. I'll contact the senior respiratory physician and hand over potential cystic fibrosis patient and ask if there are any interventions that they would recommend I'll give antibiotics for the underlying infection following local guidelines and to manage the underlying infection. Nice. Um Long term management requires a multidisciplinary approach for his chest. This patient engaged in chest physio to move mucus from his airways. We also use medications specifically mucolytics like donates alpha bronchodilator like salbutamol to improve his weight breathing. Given his weight loss, he should be referred for nutritional support. So, dietician like people said, he may require Creon vitamin. Ad EK. What do we need? Ad EK guys, he should start on a high calorie high fat diet. Give an education about his condition and advice to avoid other patients with CF who need regular follow up with his GP and local cystic fibrosis team to address the new issues as they arise. And thank you. So, yeah, so, so people have just said about the triple therapy meds. So just yeah, at the UK, you have that soluble ones. Um So if they're having problems with their pancreas, they're having problems with lipas. Oh, wild. I know about that. But yeah, nice. I've touched on a few things here that aren't in the list of ones here. Um But again, remember like I said, I have, I had, well, I didn't have time to write about this. Um but I have a lot of time to, to go through and do it in the exam. You're not gonna be able to bring up as many points, cover the main, the main points, you know. Um ok, so cystic fibrosis little summary. Um Oh, I ca I have ever c all here. Um There we go. Little summary of that again. This is not for now. Um So let's have a look then child health, which pediatric conditions we've got two weeks, what you, what you gonna revise? Which ones are the most important ones that we think? Ok, if I'm only gonna do three over the next two weeks, what ped pediatric conditions am I gonna focus on? What do you guys think? DKA bronchiolitis? Croup bronchiolitis. Yeah, croup bronchiolitis. I'll be honest. I think that they speaking to people from previous years, babies don't really tend to come up. I feel like that would be a bit of a challenge because they would be telling you this is child health and then not giving you a child's like a pediatric history to actually take, you're taking a history from an adult. So this the issues around safeguarding and stuff you can't test because you're not having to speak to a kid. So II think that it's more likely to be an older child. I wouldn't completely rule it out, but that's, that's my perception on it. Rashes would be a history. Um And it's hard to describe a rash in a history. So, II doubt something like measles would come up because how can you distinguish in a history? Measles unless I have some really nasty complications that only come up with measles which could exist. But I don't think that's likely to come up. So I probably, I'm not sure about those. Um Celiac Yeah, feeble convulsions. Yeah. A L, yeah. I mean, we had the ITP one, and the ITP one came in worried about leukemia. Um, so I think that's definitely reasonable. Sickle cell. Yeah. I wanted to bring up cystic fibrosis because they, the way that cystic fibro, cystic fibrosis is common when it comes to, uh, healthcare. Right. It's not common generally but it is common. Um, and the reason I brought it up is that I just think that it's challenging when presented with either history, I think it would more likely be an examination. And to think in a kid, this might be cystic fibrosis just because we have neonatal screening in place. Um but not all countries do. That's why this person was from Bulgaria because Bulgaria specifically don't have a neonatal screening thing for cystic fibrosis. We don't expect you to know Bulgaria doesn't I have a friend that that's why I know that. But when you're focusing on it like that, I if they introduce something like that, that might be what they're going for. But I just think in my head, in the type of patient that I expect to see cystic fibrosis in, I don't anticipate respiratory manifestations in like a 15 year old because I would expect that they would have appeared earlier. That's, that's maybe that's just me. Um But that's why I want you to bring up the cystic fibrosis one. We had it as a mock is case in, where was that? Me, maybe somewhere. And I was like, gosh, I would not, I would not, like I said it as like an offhanded thing and they were like, yeah, given the likely diagnosis of cystic fibrosis and I just wouldn't have come up with it. Um, yeah, IBD, maybe I BSI think would be more likely in, like a teenager I BDI think would probably be like a young adult station. Um, But yeah, I think people are coming up with really good ones there. I'll leave it there for one sec in case people want a picture. Ok. Which ones did I say were the most important if I was only gonna do for asthma type one seizures, meningitis? Ok? Um Again, port right. I'm gonna move this over to a picture so we've run a little bit over. I have one more case, I'm gonna go through the case. You do not have to stay here for the case. I appreciate the, the the 40 people that are still here with me. I know that somebody asked though about what would I do in the remaining two weeks and that we've run over. I want to present the answer to this to people to tell you what I would do in these last two weeks. Um In case you wanna leave and you don't want to do it, it would be best answered at the end but no one wants to wait for another case. What would I do in the next two weeks if I was going to, if, if my, if is in two weeks now, number one, I would be making my own versions of those lists of those important conditions. I'd make sure that I have them for pediatrics, for obstetrics for, like, for my specialties. Right. Because the specialties will definitely come up. So, you know, that you're gonna have one on each of those. So I wanna make sure I have both common and important ones. I've talked through a couple of them that are up on the middle website. So you can go and grab what my my lists were. But I'm sure that you will have similar lists. So I'd make sure that I've got that common important list for all of those and do the same thing for the other stuff like your cardiology and stuff. Those are more likely to present as your like really chronic ones, hypertension, heart failure or as your acute stations. So make sure we know emergencies. I would wanna cut that down as much as possible to like the, the ones that I think are most likely to come up now. Like I said, II just have this inkling that torsion will be on there. I don't know if torsion will be on there. Don't this to be super clear? II don't, I don't know, I know nobody on the thing. It's like this is not me telling you that torsion's gonna come up. I just get that vibe but like it may be that you get a vibe about a specific condition of OK, they've not done atrial fibrillation in a while and that's a really easy ECG to give me. So I'll do af and that you, you might have that the person next to, you might not have that, make sure you do that. So, and what I would be doing for those in my mind was I would make a slit set of just the management of those conditions. What would I say if I was asked to manage atrial fibrillation? Why? Because I think that I can get through any history. Given my experience, I think that the majority of my investigations are the same every time I will always do my bedside observations, I will always say F BCU and E LFT S like that's fairly similar. I think I can do that on the fly, the management. If I don't know it and being explicitly tested on it, if I don't know it, I'm not going to be able to answer that question. So I would have flashcards on what I think are those common and important conditions and just a list of what I would say in management. And I would pre split it up into long term, short term or conservative medical surgical, whatever works for you and do that way. If you have a group of people that you are practicing with, I met up with my group probably about six times in the last two weeks. Um So I would do that as much as I possibly can make sure that you take advantage of your clinical skills area session. A lot of people didn't go to it and II wouldn't recommend that, make sure you go and all of the time when I'm not doing with other people and I'm not revising that content. I would be doing the thing that I said in that very first session where every day I went on to check GPT and I said, and I put in that paragraph of our medical student preparing for my examinations and I said, generate for me a scenario and I just practiced answering the questions because the questions are the same every time, right? It's summarize the history um that it's what your top three differentials and then it will be like interpret the blood test results or something like that. Now you can ask like I give it and I say, give me a respiratory case and it gives me a respiratory case and I summarize it back to them. And I say, I think this is asthma. Please give me a series of full blood test results that I can interpret and then I interpret them and then they'll tell me if I'm right or not. This just means that I can do it with nobody else there. I can target the specific thing that I want to and I read it out loud and then I would type it down. It takes a while but it doesn't require anybody else. Um And I don't know, I just found it really useful. Um Would I do anything else? Uh I II also the, the normal stuff, take care of yourself. I didn't do that. So, um but yeah, make sure that you've planned how you're getting to and from the E as well. You don't wanna be like, stressing about other stuff and like logistics of it. Um, but that is what I would do in these past two weeks. I'd only be focusing on that most important stuff. Um, what I identify as my important things anyway. I hope that's useful. I know it's just me and like, I'm, I'm a, I'm a weird case anyway. So I'm not sure if this is what the general people would do, but that's what I would do. Um. Right. Oh, so there's a chat, would we have to cancel on scope procedures? So they say that the medication station could be counseling on a procedure, the ones that they, now, the, the reason that, that probably comes up and II might be wrong here. The reason that that question comes up is that's a really common thing to do in a, is other people's stuff not to do with us. They've said that procedures can come up in the, um, in that th therapeutics. One, but the one that they specifically talk about is electroconvulsive therapy. Now, I'm not sure did I revise for it? I did revise for t, but I'm not sure I would revise for scopes. And I'll be honest, I think the majority of scope procedures and it would be, if they were gonna do it, it would be an endoscopy or a colonoscopy, right? I think that you would be able to talk through it. OK? Because just logically, I've never seen anyone do a scope. So I may be completely wrong. But what I would be talking about is you're, you're probably gonna be awake during the procedure, but again, we'll just make sure that you double check, you'll give patient leaflets, you'll check with the senior. Um What we're gonna do is we're gonna take a tube with a camera on and we're gonna put it in said tube and we're gonna have a look and then we're gonna see if we find something, then we can take a bit of it. If we don't find anything, then it might mean that there's nothing there. Um What are the risks of this? It's gonna be a bit uncomfortable uh introducing anything anywhere risk of infection might be a risk of bleeding. Um But really, I think more of that is going to be reassuring the patient about something that they're worried about, not about explaining the procedure. Um So it, they say that you can be tested on it in the therapeutics. One. Like I said, they mention E CT specifically that's never happened before. And I think that really, that's just a remnant of Aussies, like I said, make your own decision about whether you like, believe that or not, but that II didn't revise for scopes. No worries. Um, ok. All right. So if there's no more questions, I wanna bash into this last one here. Stay along for the ride if you want to or leave if you don't want to. That's also fine. Um And we've got a similar one next week with another four. If you've got, if you complete the feedback, you can let me know what you liked and what you didn't like about this. I appreciate the four people who are joining it on the mentee, but I'm hoping that the people who aren't joining it on the mentee are uh like I say, like thinking it through in your head or speaking it out loud to do it and like as long as you're getting something out of it, it's entirely fine with me. Um So station four then remember we're standing outside, what are we gonna think? Read that through? What are you expecting? Ok. So what we have then 89 year old woman becoming increasingly confused. I'm standing outside of the door. I'm trying to think what are my main things? What am I thinking about with confusion in my mind? I don't know if you guys are agreeing with this, but in my mind, I'm going down the road of OK. Is this a psych thing? Is this a neuro thing? Is this an infection thing? That's my thoughts in an elderly patient who's becoming confused neuro thing, meaning like dementia, this is a collateral history, take a focus history from the partner and it's four minutes. So just to be clear, we wanna make sure that we do that thing of making sure that it's definitely OK to talk to the partner consent them, but it's four minutes. So we're not gonna spend loads of time on it like we would with a child here for seven minutes. So what would we ask this patient increasingly confused again? Bearing in mind might be infection might be Alzheimer's dementia vascular problems might be psych. Ok. So hopefully people are having, I think I got some answers on here. I watched you two weeks ago. I think that's a very interesting way of asking that question. Um The reason I say that is cos this, this will help us figure out if this is acute or not. It might be worth asking like, how is she normally? Because it may be that actually, she's been like this for six months. At which case, two weeks, she was still like this. How is she normally? Well, before the six months, she's normally like this, this is the new bit bowel bladder symptoms. Yeah, frailty condition, social history, sensory disabilities. Yeah. Yeah, this is a really big thing. Just make sure you know who you're talking to. Um, onset and duration. Yeah, exactly. Baseline functional status. Yeah. With elderly patients you wanna know how they can get around. So, how do they normally immobilize and also can they carry out their ADL S medications? Yeah. Right. Ok. Let's have a look at what I've put here again. This is just a way of structuring a um, uh, the history again. I'm not gonna click through it all this time. Um But yeah, you can use it as a checklist if you want. Um So our history that we get presented from her was mis you in an 89 year old female presenting with confusion, history, presenting complaint. So her partner noticed increasing confusion over the past three days normally has mild cognitive impairment, but this is different disoriented to time and place also feels generally weak and tired. Has had two episodes of urinary incontinence, which is unusual for her. She was in hospital for a fractured neck of femur which is healing well. Past medical history is hypertension and type two diabetes and a two year history of mild cognitive impairment. It's on Metformin, Dapagliflozin, Lisinopril. No family history of gi issues. Why have I said that? No, no family history, social history lives, a partner with home normally immobilizes with a stick and independent of AD LS no smoking, alcohol history, retired nurse partner thinks it might be worsening, cognitive impairment. He's concerned that it's progressing to dementia and is like, it's just wondering, I suppose, can anything be done to slow this progression? Yeah. So let me just add it here. I just wanna point it out. So, fevers, gi urinary symptoms, weakness. Yeah. And defined confused is a really important one. it's always a good idea to define like specifically what a patient says. Um Because for example, if somebody says that they have diarrhea, people will class diarrhea, anything that's like softer than normal. And some people will have a really low threshold for calling something diarrhea. Whereas somebody else might say this is like a completely liquid. So it's always just worth asking even if it's something uncomfortable like that. What specifically they mean? Also if they say down there for anything very common thing for actors to do down there, just check, you know what down there they mean? Ok. So this is our thing. What are our top three differentials have a think? What would you say with this history? What do we think it is any ideas? Ok. So we've got a few answers over here. We've got delirium secondary to eye. How did you manage to get this degree sign in here when some people are struggling for spacing? Like it doesn't say um dementia infection delirium secondary to eye Alzheimer's acute urine retention, delirium normal pressure, hydrocephalus. This is a banging answer. Uh chronic subdural hemorrhage. Yeah. Um I say that's a banging answer just because it's, it's quite a little bit, it's a bit of a rogue diagnosis, but it does entirely line up with somebody who's got confusion and incontinence. Um Yeah, brilliant. Um, yeah, a lot of people have, a lot of people have jumped to the, the delirium one. quickly. Yeah, that's, that's fine. Um, we've got dementia here as well. What's the, the other one? What's the other thing that we should be thinking with confusion in an elderly patient? Could be delirium? Could be dementia. What's the third one? This person has got weakness. Um What I was gonna say, weakness and fatigue with confusion, depression is what I'm looking for could be other ones not wrong. I'm surprised by it. Yeah, depression is the other one. So delirium secondary to any kind of infection. You're right. Pneumonia, uti any of those dementia, this person already has mild cognitive impairment. Um So progression to dementia isn't unheard of, especially if like it's vascular dementia and like maybe they've had a stroke or something. Depression is the other option, especially if they're tired. Um So just think of those three, when you're looking at confusion with this sort of picture, it's very easy to forget. I mean, I'll be honest, a lot of the time people will say dementia and forget about delirium, but depression is the one that people forget about. Even if they remember this year. Um So yeah, depression very common. Um classic example is where you'll ask them to do the mini mental set exam. Remember mini mental state exam is the one that you fill out on paper with like the the hippo and like the drawing, the cubes and stuff. That's something that you can be asked to do. So just know how to do that one. And the mocha they're fairly like easy because they require you to have like you need to, they have instructions, right? But it's just useful to know that you've seen in the form. Uh You can also be asked to do a mental state exam. Just be clear that you know, that there is a difference between a mini mental state exam, which is the paper with the Rhino and the drawing, the cubes and the number and the letter stuff. That's a assessment of cognition and a mental state exam is a, a way of assessing like the psychological health of somebody. It's a thing where you ask about their, you look at their appearance, you think about their affect and you go through all of that. That's a history structure in my mind. That's something that I'd wanna do in this next two weeks because mental exams they're not too hard, but it's not something I can do off the top of my head without reviewing it because it depends when your site block was, I suppose. Um drug side effects. Yep. We've got an elderly patient always worth doing it. Which one would you be thinking about drug wise? Any of these jumping out that might cause it? I've not, I'll be honest, I've never seen dapagliflozin abbreviated to that. Like I get what you mean, but like the fact that three people do it once. Um Yeah. Um So the thing is here is that like we've got this Dapagliflozin, we've got this episode of Incontinence. So this could just be drug side effects, but also we've got the confusion. So it could be that we've got a side effect of the medication which has increased glucose in the urine which has caused a uti which has caused delirium which is causing the confusion or is the confusion, I suppose. Um Yeah. Nice. OK. Summer wise, top three differentials we've just done. I've bashed oh oh I, I don't know why that for some reason has disappeared. Let me just scooch to that page. So I can show you whatever I wrote before are my top three differentials. Oh, I've added both in this is probably will not be interesting to you. I've added both a come in and then immediately leave animation. Um So I've said top three differential sepsis, new incontinence, delirium, worsening, dementia uti and stroke. People who have wrote hypoglycemia in the previous one. Stroke mimics equally valid to put here. Yeah. Uh Nice. Whoop. Um So yeah, immediately leave good. Uh Right. In terms of these results, I appreciate. This is small. I'm gonna read this out says Glenis June 30 09 1935 22 0 4:09 a.m. 22 96. Cross 14082 126. Cross 38.5. Now have a go talk through, what would you do if you were asked to interpret these results? Ok, so hopefully that minute is enough for people to have talked through what they would say again, like always, this is just like if I was looking at blood test results, just like if I'm looking at a image and image, I'd say this is a news chart for June date of birth, blah, blah, blah. I cross reference this with my patient. I see if there are any previous results. My recommendation as somebody sit here is to read them all out. Um I specifically tend to say whether it's raised or low. And so I would say the Respi the respirations are raised at 22. The oxygen is normal at 96 on air. The BP is normal at 100 and 40. Over 82 the heart rate is raised at 100 and 26. Oops patient is confused and as the temperature is raised at 35. Um yes and so I've lost that person thing cos I clicked on it by accident. Here we go. Um So you just a query infection. Yeah. And that would be my last sentence that I say it just summarizing what I'm seeing in front of me. Um And also remember trying to line up with your differential diagnoses, our differential diagnoses were delirium secondary to uti I maybe I never actually asked why people said secondary to uti and not a cap. But are we happy with the fact that sometimes UTI S can present with incontinence? That's not a I'm just, it, it can. Um So yeah, it could be that this, this don't really point towards dementia as much. It doesn't really point towards the depression as much. Um So yeah, so I've written, it's a news chart of the last June. The respiratory rate has raised at 22 oxygen and BP are normal pulse has raised at 126, confused and it pyre at 38.5 I should say sorry. This total is to a score of eight looking at the recommendations. Where do I look once I found a score of eight, like I've said, it requires informing the registrar and critical care outreach referral. Yeah, on the back. So you just turn it over. This is like the nicest thing to be presented with in an is um and they like to do it because people don't do them very well. Another one they don't do very well students, I mean, when I say they um the other thing that we don't do well is blood glucose. So just really make sure that you're happy with doing blood glucose because like I said, if we're not good at it, they're gonna test it. Um, yeah, so you get it, you just turn it over and on the back it has just a table. I tried to get a picture of it for this but just, it's just rubbish, getting out of Google, just turn it over and if you've not seen the back of it, you don't know what on about, go to the clinical skills department or go to the ward if you're on placement, question mark. Um and say like I can't see the back of this. Um Even if you're not in the clinical skills department, you're not meant to be there. Uh because you missed, you've done your slot already or whatever. Just ask, can I just see the back of a news chart? Um Yeah. Uh This was my luck of sepsis. So I've said sepsis because if I'm getting delirium from something and I've got a score of eight, are we happy that I should be saying this is sepsis? Would I overtreat or manage conservatively given her age? Well, she's acutely unwell. She's got a news of eight, she's pyrexial and she's symptomatic I probably would treat. Um Yeah. Um But if you have that, that y you can always bring that up at a point like I would be concerned about over treating this patient given that she's 89 So I would just consult with my senior first to ensure that she they want to proceed with with medical management. That's entirely reasonable to say. Um So yeah, this is, we're gonna say sepsis, we're gonna say sepsis cos we have query infection high in new school patients on it. Well, se four, how do you manage this patient again? Just read it out to me. Well, not to me but just read it out in your room. Ok. Hopefully that's enough time to talk through. So how would you manage this patient? Any ideas have this pumpkin that when you squeeze it? A ghost comes out. I'm saying that because I forgot that I had a camera on this entire time and I imagine that you've probably seen me playing with it and I think it's weird to not now acknowledge it now that I've remembered. Um Yeah. So if people have not said the sepsis six after I've just said this is sepsis. Um Yeah. So we're gonna start the sepsis six blood count and you, you need to explain what it is, right? So do the sepsis six. And then you say which means so take blood cultures lactating urine output via cat. Yeah. Oxygen antibiotics. IV fluid. Sometimes people don't like to put in catheters if someone's got a UTI. So I'd probably check with someone first but that's, that's more for you than for is um analgesia for pain. Yep. Any equal two large can catheterized analgesia, measure urine output, blood cultures, lactate antibiotic. Local gus. Yeah. What method? What route antimicrobials? Yeah. Fluids, vasoactive agents, oxygenation ventilation support. Help six antibiotics. Lot. Yep. Um, thing that I would add just to, um, make your answers. I, I'm assuming you're just typing it like this but to make your answers a little bit better when you're reading them out and also to make them take up more time. Um, because you will feel like you run out of things. Like I said, everything I sort of say involves some waffle of some degree. So I do that. Oh I'll do an a to be approach um when we're talking about the uh so tell me the route. So we're gonna give you antibiotics. IV um Tell me you said fluids, what kind of fluids? It's probably gonna be 0.9% sodium chloride, oxygen. How are we giving it? How much? Um So if you can be specific, especially with something like the sepsis six anaphylaxis. Anything else? Maybe M I ones if you know it. Um But sepsis six and anaphylaxis for sure. I would hope that, you know, the adrenaline doses um and the route and you can tell me where we do it. Yeah. 15 L by. No be mo this is all it for an acute situation anyway. Yeah. Brilliant. Good job. Um Yeah, VT O prophylaxis. Sorry, I didn't even notice that. Yes, it was really good there. Um I've put my example here again, just as like a, I think for you follow up, this patient is clearly unwell. So I assess the A two B approach to get seen involved earlier due to my high suspicion of sepsis. So I start the sepsis. Six, give high flow 15 L of oxygen through a non rebreathing. I take blood culture and then give IV broad spectrum of antibiotics. According to local guidelines, I will give an IV fluid by dose of 500 mL, 0.9% saline. Um I'll take a blood lactate through a VBG. I will offer urine output to be measured which may require insertion of a urinary cath. This management plan is a lot shorter than the previous management plans. Why this was an acute station? So we didn't have to give as much um if you want it to really go above and beyond, just gonna put this in here. The, the best thing to say, if you're doing a management plan and you wanna go above and beyond is gonna be the, the human factors. Social part of it. This patient is 89 has come in and was acutely unwell. Just make sure that we're like, just consider the fact that we're gonna need MDT input to get them back out, into, out into the to the world again. Does the partner need support? How old is the partner? Just asking those sort of questions? Like hopefully, you can all bash off sepsis. Six. But only a few of you will think to do that stuff about social stuff. So I'm telling you now think to do that stuff about social stuff. Do they need psychological support because they were so acutely unwell. Um And lastly, I've put on here, this patient requires an ABG do it and then there linked to the clinical skills linked to the Gits. Again, this will be up. Um I've put this on there so that I can give you my little bits of advice again, wash your hands again, speak to the patient. Same thing modified Allen test. Don't forget to say that you would assess the collateral blood flow to the hand. Um uh Yep, say that you'll do that. You may be asked to do it on the examiner of the patient and this to be clear, this is the squeezing down of the arteries and then removing, yeah, the ulnar one, you may be told that the collateral flow is fine and you don't need to do it, but you have to say it out loud either way it should be the first thing that you're saying after you're consenting. Um And you're doing the the risks. Um ABG needles just make sure that you are familiar with the ABG needles for us specifically, they changed the ABG needles within two weeks of the exam and they were like, oops and I'm like, mm so know the ones that are in the clinical school labs. But if you're on placement, ask on placement to have a look as well. Make sure you know how to make the needle safe. Some of them will have caps that go on. Some of them will have a little rubber bug that you stick it into. Make sure you know the ones in the clinical skills one, like I said, if you're on placement at the moment, I don't know if you guys are, but if you are, then go and see it there because you'll see a different one, make sure that you know how to do that. And if you're not familiar with the needle, I would say I'm happy trying to take this A BGI have not seen this type of ABG needle before I'm unsure of how to make it safe. You can ask how do I make it safe? Or you can say for the purpose of this, I'm going to put it immediately into the sharps bin cos I do not know how to save this needle. Therefore, you've shown I can do an ABG and you've also shown if I'm unsafe, I'm putting it in the bin, right? Um Hopefully that makes sense. Um Right. So that's it. This is my fing on sepsis. We already did acute stuff. This is the 16 I do with done. That's a feedback form, but it'll don't, you don't need to scan it because it will ask you to do it when you leave anyway. Right. Have we got any questions? Thank you for sticking with me. We've, we've third since the beginning. Ok. You flirt. II, hope, I hope it is useful. I just, it's sort of at that point where like, you know, most of how to take the history and everything. It's just like trying to give you more stuff. Um I'll put the stuff in the, I'll upload the thing and if you want, we can do similar thing again next week. Um If on the feedback form, you have any suggestions for, maybe it was really slow and you actually hated it um or anything like that, do just put it on and I will do my best to do whatever I can next week. I know that it ends up being a little bit long. Sorry. Um But yeah, if there's anything specific that you want next week, even if it's specific pathology, like if you really want to have a case on multiple. That's right. I guess I would keep going. If you want a case on MS to come up, then I can do a case on MS. Um because just sometimes it's just useful to see what questions somebody else would ask. But like I said, have a patch with G BD. Honestly, I think it's great. Any questions though, I'll hang around, you guys will do fine. I have so much faith. Oh Damn. Why didn't I in my, in my two week plan, say come to my session could have done a sweet plug. I can see we've got like 20 people still here. So I'm assuming you're all frantically typing really long questions. So I'll keep waiting. Oh, yes, I can. It's in my original introduction thing, but I appreciate that was back in December. Uh Why did I say that? Like ki uh let me just get it. Uh oh, you know what, I may have to ask you to take a picture of it I II screenshot it. I was clear, so lazy at the time. Um It's here. Um That's why I would put and then this was back when I had the crazy background for every slides, but some people didn't like it. Um So there's that, that's what I put into chat GPT and then like this is the sort of thing that it comes out with. Um and then comes out with like a case and then there's vital signs and stuff. Sometimes you might need to do a bit of digging around with it. So sometimes it might tell you the differential diagnosis. Um So if it does do that, you may need to add in, do not tell me the differential diagnosis. And if you don't like the way that it's telling you it's giving you blood test results or something, say, can you try again? But I can't see the, the chats at the same time So I'm hoping that's ok. Ok. There we go. Thank you. Um, and I'm assuming people know how to get on chat GPT, but I'll put that in the chat cos I do actually have that. It's useful if you're lonely like me. Ok. Cool. All right. So it seems like, look good. I think the remaining people are just the people who sleep. I think I just have very, my dulcet tones as Marcus Coffey would say it. My dulcet tones put you to sleep. Um, I really hope that you're not like paying attention to the screen and just listening to me. Oh, thank God someone left. Right. I reckon that's probably ok. Uh I'll just put it here if any more questions, email me and I will get to you. All right. Thanks everyone. Oh.