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Good afternoon, everyone. Please let me know if the video and the sound is clear and I hope you all are doing well. We'll be starting our session in like two minutes. Maybe if the sound is clear, please uh let me know in the chat box so that I can start the session. Thank you. You can just type PS or no and that's it. Ok, perfect. Thank you, Doctor Najma. All right. So today we are going to talk about history taking stations, which will include the structure, a few examples. And at the end of the session, we're going to practice the history taking sessions um like a very random station. Uh It can be anything, it can be chest pain can be back pain, it can be any of these. So those of you who are actually a little bit aware of um the structure and uh started there practicing as well. And even even if you have not, that's uh completely fine. You can start your practice today. That's a good opportunity. So please let me know in the chat box if you want to uh practice at the end of the session. So I will be taking the mock, I will be the simulator and I will be giving feedback at the end of the mock. OK. So if you are interested, you can either drop um a text over here in the chat box or you can drop a text in the whatsapp group as well. OK? Either one of us. Fine, right? So today's session is all about history taking and psychiatry, right? So let's begin. So let's talk about the history taking station patients at first. So what happens is it can be um it can either a patient um who is a new patient like you haven't seen this patient before. So all you have to do is you have to make sure that you confirm the name, identity and the concern as well. Act like you have not seen this patient before, right? So you have to make sure you do not pretend that you have seen this patient before or you do not pretend to be familiar to the face. OK? You have to be um very new to the patient and uh uh um like your approach should be very, very friendly. OK. So this uh this um patient feels comfortable to share all of his or her concerns because this is a new patient. There will be a lot of things you might not be expecting from the patient. So please make sure that um you uh start taking each and every details and concerns of that patient. OK. So it can either be a new patient or it can be a patient which you saw before. Like it can be a patient who is here for his or her followup. So you have to uh make a slight change to the approach. Ok? You cannot really say that. Hello, I'm doctor. No, I'm one of the doctors here. Can I please confirm your name and age and what seems to be the problem? So you cannot really start it that way. Yeah, like the patient will think that I have met this doctor before he is or she is my GP and this doctor is acting like she or he hasn't seen me before. So the patient might feel a bit neglected. So that's the reason why we have to make a difference between these two patients. So they like it actually will be led by the a piece of paper that will be stuck outside the room or it can be uh details a very, you know, it can be a, a hint from the patient as well that you know, you have seen me before if it is not written on the piece of paper. So you will be given hints. Don't worry, you don't have to guess or you don't have to uh make it on your own. It's just that you will be having hints, so you'll have to act accordingly. Ok. So it can be either a patient who is a new patient who is um, new to you, who is new to the hospital or the setting or the GP or it can be a patient you have seen before he's here for the test results or follow up or anything for uh, making sure that the treatment is going according to the plan. Ok. Right. Ok. Right. So we are talking about the new patient first. Ok. Whenever there is a new patient who has appeared to us, uh maybe it can be a GP it can be an emergency department, it can be a hospital setting, it can be medicine, psychiatry, whatever the department is, if it is a new patient, you have to make sure you follow a certain structure. So I have created this um like window kind of things just to make sure it is actually set inside your head. So I'm really sorry, I forgot to confirm that if the slides are visible just to make sure you drop a comment that yes. So I'll be understanding that the slides are visible to you. I'm not really sure. Um even if I can see that this is being presented, but um because of this uh slight uh technical problems yesterday, I just want to make sure that the slides are visible because if it is not, then there is no point of me explaining uh um without the slides just drop a comment on the chat box that slides are visible or yes, and that's it. OK, perfect. Thank you, doctor, right. So there are like seven steps I always remembered in terms of a new patient, it's like the first step is always be one. I'm going to talk in detail in, in details, in depth. Uh when the next slides and the following slides will come up. But it's just that this is the basic structure you have to keep in mind in terms of a new patient. So whenever there is a patient comes to you, uh you don't know anything about this patient. So you follow a certain structure step. One is P one. OK. I'm gonna talk about this P one later like in the next slide immediately. But I'm just going to talk about the steps first mentioning the steps. OK? So P one and then between P one and P two, there is a gap. OK? So this gap consists of a few things. After P one, you have to make sure you talk about anything else you have to ask. Is there anything else? There is one more thing, the concern. So here you can include your concern from IC part. This concern can be here as well. Then you have to make sure you are talking about the differential diagnosis, which is AD Ds. And then you also have to make sure if this is a concerning patient, you have to make sure you mention the red flags as well. OK. So these are the things that you might want to mention between P one and P two. OK. After P one, there is P three, which consists of DAS. After that, you have to talk about Mef Tosa, which is in the morning. These are basically the in the mornings you have to talk about. Don't worry there will be slides uh after this slide which will actually uh describe which these days are and Mef Tosa consists of OK. OK. After Meza there is another box, you have to make sure you ask about anything else. And as I have mentioned in my yesterday session that you can include your expectations just before the examination, which is basically you have to ask the patient, is there anything specific you are expecting from us? You can also include this expectation things after the examination as well. I usually used to prefer after the examination. But to be honest, it totally depends on how it's going between you and your patient. OK. After the examination, you have to give a provisional diagnosis. Like you cannot really say that I am pretty much confirmed that this is the case. You can't really say that this is a confirmatory diagnosis cause you have to double check with the senior. You have to wait for the investigation results and the scan results as well. So this is a provisional diagnosis you have to give to the patient. You have to say that. OK. So um this seems like you might be going through this. So what I can do is I'm going to talk to the senior. I'm gonna double check, I'm gonna wait for the results and when you'll be following up with me, we can discuss further treatment plans. But now that you have these symptoms, we are going to work on those first. If it doesn't work, we can come up with some other treatment plans as well. So this is how you talk about the provisional diagnosis. And after that, you have to make sure you do the management. So the management actually um consists of three ci would say I'm not really sure whether it's visible. So I've written, there are like three C. You have to make sure you remember in terms of management. Of course, we have talked about the steps of management yesterday, but these three C are something you cannot forget when you are talking about the management. So the first C is consent, you cannot really force the treatment plan to the patient. You have to make sure that you are taking permission or consent from the patient before uh treating the patient or prescribing the medications. So you have to tell the patient that you know what you are going through this, this and this. So um I think we can work on those things by prescribing you this medication. Are you ok with that? So make sure that you are taking consent from the patients OK. So you can't really force this thing. You can't really uh you know, you can't really say that, OK? So I'm gonna give you this and you are going to follow this, you're not going to order the patient. So this is the consent we are talking about. The first c is consent. OK? The second thing is managing the concerns. OK. What about the concerns? A patient can come with a migraine situation? Ok. So the patient might say that, you know what I'm having this sort of uh headache after, you know, um it, it, it actually lasts as long as um 48 hours sometimes or it can be as little as, you know, five hours or six hours. And it's getting triggered by light, it's getting triggered by flashes and I'm getting some sort of, you know, I'm s I'm seeing some sort of rings of light in, in front of me, which is basically the aura. So you, the patient can say that, you know, uh this is what seems to be um uh happening with me lately. So you can all uh like uh after uh ruling out the differential diagnosis, you are coming to a certain point where you can guess that this is a migraine. But instead of managing the symptoms, you can first ask the patient that what seems to be the main concern of yours. So the patient might say that, you know what um these um these headaches are something that has not happened before. Ok. This is very, very, very new to me. Uh This is something that has, um, like that is something, um, bothering me that has been bothering me for the past couple of, uh months, uh, after I started my job as a teacher. So it's very, very stressful as I, and I think this migraine has started after I started my job. So what is the difference instead of jumping and rushing to the medication? You have to manage the concerns first. Ok. So you have to talk about the stress management instead. Ok? Even if you like, don't worry about the time, even if you don't have enough time to talk about the medication that you know, instead of blabbering about your knowledge, you have to first take care of the concerns of the patient. The patient is really worried about the stress patient cannot sleep due to stress and workload. So what you can do is you are going to say to the patient that you know what I think you can take a little bit of a break or you can work on your sleeping schedules. And um you can also make sure that, you know, you work on your stress management. If there is anyone else in your family who can help you with the chores or um something else that you are worried about if you have Children, uh you can just divide your work with your partner to make sure that the work is divided completely. So you are talking about the management of the concern instead of the condition first. Ok. So this is a very, very good approach that you make sure the patient's concern is being addressed before the symptoms are being addressed. Ok? So after if you have managed the concerns, if you have enough time, you can talk about the condition as well. Ok. So you can say that, you know, now that we have, uh, kind of a solution of, uh, to your stress management, we can talk about a few medications that might help you with your migraine. So you can start with the painkiller. The very regular one like no paracetamol. If it doesn't work, we can, uh, talk about naproxen. If it doesn't work, we can, um, we have some long term medication as well like Sumatriptan. So if that doesn't work, you can just follow up with me. We can think about something else. Ok. So this is how the management goes. Three C, you have to take consent, you have to make sure you manage the concerns and you have to make sure after the concerns, only after taking care of the concerns, you talk about the condition, so manage the condition at the end. Ok. What we usually do is we tend to talk about medication at first, which is, I think is not a very good approach. Ok? So we have to make sure we take care of all these things in terms of management. And also if you think that you don't have enough time to summarize all the management, uh like you don't really have time to talk in details in uh in terms of the management, what you can do is you can actually summarize the keywords or key points. Like, you know what today we are going to talk about um how we can work on your symptoms. And then we can uh you know, uh come back to the main concerns that you mentioned earlier or you are going to mention if you have any other concerns, we're going to talk about that ta talk about that. And after that, we are going to take care of the symptoms, ok? But for now I'm going to give you some medication and then, you know, there are a few things uh which we have to make sure we have to be very, very careful about, which is basically the safety net thing. And after that, uh we can say that you have to make sure you follow up with us. Is that ok? Uh So what do you think you, we might be um talking about at first like we leave the decision on the patient, what she or he wants to talk about at first. So we have summarized to the whole management thing and then we can start talking about each point in details like this way what we can do is we can we have actually talked about all the key points in terms of management so that you don't really get zero out of four in terms of the management domain. If you have, you do not have enough time at the end of your station. OK. Basically don't panic. You don't have to like uh talk about each and everything in details. This is how you uh take care of the management points. OK? If you don't really have enough time, right? If you have any questions, please make sure you drop that in the chat box. All right. So I'm moving on to the next slide. OK. So p one there can be any sort of patient, a patient with some sort of pain, a patient with some sort of other symptoms, it can be, you know, um some sort of sleeping problem, it can be anything but pain. Ok. So there are different structures for different complaints. If the patient has pain, we are going to memorize this Socrates thing. This is a Pneumonic and if we have any other symptoms, we can talk about this otar thing. This is also a pneumonic as well. And if the patient is coming up with some sort of discharge, the thing that we follow is uh trac it's tr ac OK. This is how I used to remember. This is uh also something I got from a few academies as well. So in the help of their, you know, good uh teaching patterns and also my own memorize um techniques. This is something I came up with. So pain Socrates, other symptoms, otira and discharge tract. This is a very common Pneumonic uh taught by a lot of academies these days. So that it's easier to remember all the complaints and all the questions and we don't really forget about certain important questions. OK. So we can start with the pain first. So Socrates, S stands for sight. If the patient is having some sort of headache, we can say that. OK, so where exactly do you have this pain? So patient is going to say that, OK, you know what the patient is? The the pa I'm sorry, the pain is actually on the back of my head. So it's not really all over the head, it's just on the back of my head. So sight is very important, right? Second thing is onset. How did it start? So you, this is sort of an open question I think. So you have to ask the patient. So can you please tell me that? How did the pain start? So in that one single question, the patient is going to actually reveal a lot of things that you need to know to make sure you can manage the patient. So he's going to say that you know what this pain was um very dull at first. So what happened is I started watching the television and uh II felt like the pain was going all over the head and then it was actually limited to the certain part of my head. So it's actually getting worse as well. So, you know what, even if you don't ask about the, you know, exacerbating factors or, you know, radiation or anything, the patient has already answered the questions on his or her own without even you asking the patient that where exactly is the pain or is it radiating the patient has answered already a lot of questions. So make sure you do not repeat those questions. It's gonna take a lot of time of yours. So we have to save them as much as we can, right? So the 2nd 3rd question is character. What type of pain? See when I said, the patient has said that this is a very dull pain. It was, it started with a very dull uh situation. And now it's like a very sharp pain, right? It's like kind of stabbing me on the back, on the back of my head. So you already know the answer to the character of the pain. So you do not repeat the question you can't really ask after that. So, oh, so can you please tell me what sort of pain is it? What sort of characteristics of the pain is? So the patient is going to say that, you know what I just said that this is a very dull pain why are you asking me this again? So it takes at least uh 10 seconds of your time, which is very precious, you know, in terms of eight minutes. So uh character after that, you have to ask the patient, is it radiating anywhere or is it just limited to a certain point of your head? So if the patient has not answered that already, the patient is going to say that, you know what uh this pain is going towards the front of my head as well. In terms of chest pain, which is a very important scenario, the M I patients or Angina, the patient might say that. Ok, uh in terms of M I, the patient is going to say that the pain is radiating on my left shoulder and my left jaw and everything else as well on my left side, basically. So you have to make sure you talk about the radiation, radiation is very important if it's getting spread to other areas of your body parts or not right after that, the a stands for associated symptoms. So you are going to ask the patient that is like um uh uh you are having this sort of um headache. Uh Do you have any other symptoms? Uh OK, so you have to ask that, are you having any sort of uh nausea, vomiting, because this is actually leading to some sort of migraine kind of situation. So you can ask that. Ok. Are you having some sort of triggering things after uh before the pain starts. So there are some associated symptoms which will actually lead you to the diagnosis that you are trying to establish. Ok, so as I've mentioned yesterday, you can't really force it. You just have to ask you give the patient enough opportunity to talk about the symptoms. Ok. So you mentioned associated symptoms after that, you have to ask about the time. So t stands for time. You can ask the patient that so. Ok. Is there a certain time you're getting this headache or it's just all over the day or is there a cert, is there a certain time which actually triggers the pain? This is all about the time? Ok. So in not in terms of headaches, basically, but there are a lot other concerns where the time, the timing is actually very, very important. Ok, so we can talk about it when we are, we will be practicing uh the mocks at the end of the session, right? E stands for exacerbating factors. Is there anything that makes the pain worse? Is there anything that makes the pain better? Ok. That comes up with a lot of solution to your management. So the patient might say that you know what, the pain doesn't get better with anything, but it actually gets worse when I'm looking at some sort of bright light or um not being in a dark room. So that actually triggers my headache a lot. So these are the exacerbating factors that will actually make, uh, that will actually help you to make a confirmatory diagnosis of coming to the point of diagnosing or establishing the migraine. Ok. So this is not a confirm your diagnosis. You can actually go through a lot of investigations and scans if you want to establish that, but it's just a provisional diagnosis, you're going to guess at the end. Ok. So, exacerbating factors, very important, right? Whenever there is a pain, you talk about the severity, so s stands for severity, you're going to ask the patient. Ok. So I'm really sorry that this is going on with you. But, uh, can you please bear with me for a few more seconds and actually let me know that on a severity of 1 to 10 where, where one is the least pain and 10 is the most severe pain. Can you please, uh, make sure you can, you know, place your severity of the headache on the scale of 1 to 10? So the patient might actually think that, ok, how severe it is? It can be nine out of 10. Uh, it can be three out of 10. If it's dull, it can be four or five out of 10. If it's some sort of, you know, um, subarachnoid hemorrhage, for example, uh, the patient might say that this is the worst headache I've ever had. So, you know, this is just 10 out of 10 help me. So severity is very, very important to ask. Ok. So, Socrates is basically site onset character, radiation, associated symptoms, time and exacerbating factors and severity at the end. Ok. Very important to memorize. So when I initially started practicing, I used to be like, ok, I have to maintain our eye, an eye contact with the patient. I have to have a smile on my face. I have to be friendly with the patient. And also I cannot repeat the questions and I have to memorize all these things. Oh my God. And how am I going to be able to do all of these together? And I was like, I kept forgetting each step because I have um I like on the back of my mind, I have to, you know, structure that thing. And what I used to do is when I was trying to memorize the Monex, I actually missed out what the patient is saying. So what is the solution? Uh the solution is practicing. If you practice a lot of times you are actually going to get a hold of all of these, you will be able, of course, you'll be able to maintain both listening to the patient and structuring those steps. It is going to take a little bit of time. So the more you practice, the more you will be able to get a hold of it. OK. So practicing is the key basically, right? In terms of any other symptoms apart from pain, there is another pneumonic, which I'm, I think a lot of you might be familiar with, but still I'm going to talk about this. So O de Barra, O is onset, which is kind of similar to Socrates, but there are a few things we're not going to talk about in terms of any other symptoms except for pain. So onset if the patient comes up with some sort of depression. So you're going to say that, ok, so I'm really sorry that this is going on with you. But, um, when did it start? And how did it start? Can you please tell me if there is anything particular that happened before all of these things started or before you started feeling this way? So you talk about the onset and then you talk about the duration to have to ask the patient, uh, how long this has been going on for? Right? So duration is very important after that progression. You have to ask the patient that, ok, so you are saying that you are feeling very sad for a couple of days or weeks or months, whichever way it is. So do you think it's getting worse with time or do you think it's getting better? So, what we did in pain, we said, we asked that if there is anything that is making it better or worse, we can ask the same thing in terms of other symptoms as well. But it's better to ask this way that if it is getting better or worse with time. So the progression is basically with time. So you have to ask, or you have like you would like to ask that, you know, um, can you please tell me, is it getting better or worse with time? Is there anything space effect that's actually helping with you with dealing with all the situation and symptoms? So that's about the progression. OK, after that, aggravating factors. So basically, this is the associated symptoms that we talked about in terms of pain, the Socrates of pain, the aggravating factors is basically, if there is anything that is making the feelings that you're having worse. Ok. That's basically the, so, um you know, um the exacerbating factors from Socrates, but we actually divide this thing in terms of Otira, which is one is aggravating factors and the second one is relieving factors. So r stands for relieving factors. So, is there anything that is actually helping you dealing with this uh situation? Is there anything that helps you with, you know, um feel uh less depressed or less, uh you know, sad, which makes you happier in terms of depressed depression. It's just an example that I'm talking about, right? And then at the end, we talk about any other associated symptoms. So, uh we're going to talk about the psychiatry structure after the history taking structure. But still, I would like to mention that if there is any associated symptoms, like, you know, um if, um if you are having some sort of sadness, is there, um, like, are you having some sort of sleeping problems as well? Because of your sad sadness, uh because of your, you know, loneliness, are you having some sort of problem with socializing as well? So these are the associated symptoms. You can talk about the end of your um um o ok. So we have talked about the symptoms in terms of pain. We have talked about symptoms in terms of other complaints. Now comes the discharge, if the patient is having some sort of pain or for example, it can be um um a woman with some sort of uh discharge or it can be a gynecologic case as well. So any discharge, we talk about four things, timing, relation, amount and color or consistency. So the pneumonic is basically crack. So T stands for timing. When did it start? And how often do you notice that the discharge is going on? Ok. If it's an emergency case case, it's completely different. You have, you just have to ask that, when did it start and how did it start? That's it. You don't have to ask how often. So it actually you can start according to your own common sense, right? So timing, T stands for timing after that relation. So R stands for relation. Uh for example, if a patient is having some sort of um, bleeding with his, uh, you know, vomit, his um, um, vomiting blood. So you can ask that. Is there any, you know, a procedure that he went through? Uh, it can be, you know, any, any procedure. So you can ask the patient that? Ok, so did you recently go through any sort of, um, you know, um, procedure? So the patient might um, open up about that thing, so you can say that. Ok, so you went through this. So that might be the case. So relation very, very important. OK. Third thing amount. So a stands for amount. What was the amount of the bleeding that you noticed? It can be as a little as spool full. It can be as much as bucket full of blood or the patient might die if it, it's a BT buckle like bucket full of sorry bucket full of blood. So it can be anything. So you have to ask about the amount as well and at the end C stands for color and consistency. So you don't really know that whether it's a blood or whether it's a discharge or whether it's some sort of, you know, uh pus or not. So you have to ask about the color, you have to ask about the consistency. So uh you don't really have to mention these words. You can paraphrase according to your convenience. You can say that. Ok. So can you please mention that? Uh what sort of you know, uh discharge. Have you noticed? So the patient might just come up with, you know, this is a very um gray kind of um you know, um sputum that I noticed or it can be greenish as well. So when you talk about the color, you can ask that. Ok. Have you noticed that how thin or how thick the discharge is? So what's the consistency if you have noticed anything like that? So the patient will come up with a? Ok. So this is very, very thick and this is bothering me and this is very gross. So color consistency, all of these things is going to lead you to a certain diagnosis. You're going to talk about the end. Ok. So discharge, timing, relation, amount and color or consistency. So this is the T ra in the morning for the discharge. Ok. Any questions so far, please let me know in the chat box? Ok. Right. So we actually have to talk about the red flags as well. So we have talked about the, the small box between P one and P two, right? So after we are done with the P one, in terms of pain, in terms of other symptoms or in terms of discharge, we have to make sure we ask the patient, is there anything else? Ok. Is there anything else you wanna talk about? It can be anything? So you don't really rely on the P one, the basic symptoms, patient might have other concerns as well. So please please make sure that you actually ask the patient at the end of the P one that, is there anything else that I have to be, um, cons uh I have to know about or you are concerned about? Ok, after that, uh, after that, you have to make sure that you ask about the main concern, right? So you have to ask the patient that, ok, so now that you are having this, this and the uh these symptoms, um, can you please tell me that, what is your main concern basically? Ok. After that, you have to make sure you actually rule out a few D DS like the differential diagnosis. For example, if you uh the patient is having some sort of, you know, um uh chest pain. So you have to rule out a lot of things in terms of chest pain, right? So you have to rule out Angina, you have to rule out mr you have to rule out uh some sort of lungs problems as well. It can be anything chest pain is a very vague thing. Ok. So you have to rule out other differential diagnosis as well. Ok. And after that, if you see the patient is actually uh having some concerns, it's actually the red flags we have to talk about, right? Ok. So now we, now we are going to talk about the red flags. Ok? So if it's a patient who is uh an elderly patient or the patient might be having some sort of concerning symptoms. Like, for example, if the patient is having some sort of uh symptoms that actually is a bit concerning in terms of cancer, maybe or maybe some sort of, you know, um, like, basically we actually talk about the cancer symptoms in terms of red flags. So, and the patient might be having some sort of bowel cancer. So what are the red flags of these concerning things? Anything leads to the red flags? Please make sure you ask about all of these things. So this is basically the morning of Flaws fl Aws. So f stands for fever, you ask about the fever. Ok. So are you having, are you feeling warm if you're, have you measured your temperature recently or lately? And after that, you have to ask about the lumps or bumps or lethargy, lethargy. So you have to ask the patient, have you been feeling lethargic re recently or have you been noticing any sort of lumpiness or bumpiness anywhere in your body? So, L stands for that. Ok. After that, we have to ask about the appetite. Ok. So appetite, have you been noticing that your appetite is um decreasing recently or you ha you are losing your appetite? How, how good is your appetite? You don't really have to ask that. Are you losing it or is it getting worse with time? You don't have to trigger that thing, you can ask the patient, uh very generally that, how good is your appetite? Are you feeling like eating everything or um, you think that you're losing something like that or you are not feeling like eating as much as you used to before? So you can actually paraphrase that thing. Ok. After that, you have to ask the patient about the weight changes. Like if you, uh have you noticed that you have been noticing some sort of um, like your clothes are getting baggy or you are uh noticing that your clothes are getting, uh, you know, uh tight or something? You don't really have to mention the word weight. You can actually paraphrase this way that are you not, have you noticed recently that your clothes are getting uh baggy these days or you feel lighter before, lighter than before, something like that? Ok. After that, we can ask about the sweating, which is also a very, very, I'm sorry, big red flag of um, any sort of uh concerning symptoms. So you have to ask the patient that, have you been noticing that you have been sweating a lot? Uh Have you been noticing that you are, uh, the pillowcase or bedsheet is uh drenched right now? I'm sorry. Ok, guys, I'm sorry for the break. I was having a very bad, uh, so I'm having a bad sore throat these days. It's because of the weather changes in the UK. So the temperature actually dropped from like literally 25 degrees to five degrees overnight. So it's very bad these days. My apologies, right. So we were talking about the red flags and then we are going to change the slide, which is basically the P two. OK. P two is all about the past. OK. So P two consists of the past history of presenting complaint that the patient is having. Now, we can ask the patient that. Ok, so how long has it been going on for? Right. So is it something that's very new or this is something that has been going on for a very long time? So this is basically all about the past history of presenting complaint, right? The next thing is past medical issues. Have you got anything else? Have you ever had diabetes? Do you have hypertension? Do you have any problems with your weight or anything else? Ok. So any past medical issues, right. So P two is all about past past history of presenting complaint and past medical issues like other medical issues apart from the presenting concern. OK. So that's P two, basically sorry. OK. This is interesting. P three, P three is Daza, this is a Pneumonic for diet exercise, social smoking, sexual or stress and alcohol. OK. So what happens in all the stations is we don't really have to mention data in terms of all the stations. OK. If it is not relevant, we don't really have to mention diet exercise, social or smoking or stress history or alcohol history to a patient. For example, if the patient is coming up with some sort of emergency situation, the patient is saying that ok, doctor, you know what I'm dying, I'm dying. Ok, I'm having this chest pain and I think I am dying. Please help me. We don't talk about the diet. We don't ask about the exercise. We don't ask about the alcohol or social or stress situation in the in this patient. Ok, because this is an emergency case, we can't really have that much of time. We can't afford to have that time to ask about all these unnecessary things. Yes, what we can do is we can say that, ok, after you get better after your treatment, we are going to talk about a few plans that you are, you might be interested to incorporate in your lifestyle habits that will, that will actually help you with your symptoms in the future. So even if it seems very relevant, you don't really have the time to talk about it. Ok. So you can talk about it at the end of the consultation after treating the patient after making sure the patient is comfortable but do not waste your time by talking about all of these things. So sometimes what we do is there is a structure data. Oh my God, I have to include diet exercise, social smoking, sexual history, stress, alcohol, all of these things OK, so there is a data thing. So I have to include that thing. No, it doesn't work like that. If you feel like this is not relevant, don't include that you are not bound to include data in all of your situation in all of your patients. OK. For example, data is basically very important in terms of those patients who have a lot of time to get themselves treated. For example, it can be a psychiatrist station. So in terms of the patients who actually have some sort of psychological problems, diet exercise, alcohol, and the s the social smoking, sexual and stress thing is very important. So that is very relevant to the patients who are actually having some sort of uh problem going on in your, in their social life or maybe in their uh in, in terms of the psychological problems, in terms of their sadness. So these are very important in terms of the psych psychiatric cases. But whenever the patient comes up with some sort of emergency case, it's not necessary to mention all of these things. If you have enough time, what you can do is um you know what this thing seems to be the problem, which is, which might be related to your diet. So can you please tell me that what sort of dietary changes you have made recently or if there is anything concerning about your diet? But if this is an emergent situation, we don't have to mention that. No, no, no, not at all. Ok. Please make sure you don't do this mistake. If you do it, you might actually fail the examiner might think that this is an emergency case. If you miss out one single management plan. In terms of this patient, just by wasting your time by talking about the diet and exercise, you might fail the patient. It is that crucial. So please make sure you do not make this mistake. Ok. Right. But yes, we have to make sure we know about this structure. The diet. How many, like, uh, what is your food habit? And if there is any changes that you have made recently exercise, how often do you think you go out for a walk or how often do you think that, uh, you actually move a little bit, uh, um, then social history. How, how good do you think you are social and how, how many friends or if you have any friends or relatives or any one you can talk about your problems with? If there is anything, any neighbors, anything like that? Ok, then we can talk about the smoking history. It's like, uh, please don't take it personally if that. It's, it's just that this is a very important thing we have to ask you about. So, do you smoke? Do you drink alcohol by any chance? And I'm really sorry that these are a bit personal questions, but it's very important for you. Know, taking uh a la proper history from you. But can you please tell me, are you sexually active? So please sign post before ta you talk about the very, very sensitive issues? Ok. Signposting one more thing you have to keep in mind. Ok. You can't really say that. Ok. So do you smoke? Do you drink alcohol? Don't be that robotic. Do not follow the structure blindly. Just think a little bit about it. If you are the patient and you are visiting a doctor, how would you feel if the doctor talks to you this way? So just think that way. Ok. And after stress, uh about the stress, are you having some sort of issues recently or that's been bothering you? So that's about the stress. Ok. So daa keep that in your mind, do not incorporate in all of your stations. Ok. All right. Any questions, please make sure you drop in the chat box. Ok. So there it comes me foza. Uh this is the thing that is very important in terms of all the stations, medication, right? You have to ask the patient, have you been taking any other medications? Ok. Because of the medication, um you know, um interactions. Ok. So drug drug interactions, there can be side effects if you are actually prescribing another medication while the pa patient is already taking some other medication. So medication history, very important. You cannot miss that out. All right, allergies. Uh, this is very important in terms of the pediatrics cases. Basically, I most importantly, but you have to ask about the allergies before you prescribe a medication. Ok, so what happens sometimes is a patient presents with some sort of uh emergency situation? The patient comes up with some sort of severe, severe, um you can say chest pain maybe. Ok, so the patient is like doctor, can you please give me a medication right now? I need to live. I cannot die this way. Can you please give the medication like now, like immediately. So you cannot really prescribe the medication without talking about a little bit of the allergy situation or before taking the history. So no matter what, you have to convince the patient that can you please bear with me for a few seconds, it's for your own good. If I, if I take a little bit of history first, I'll be in a better situation to prescribe you a better medication and you, I'm, I'm sure you will be having um a more comfortable feeling. I'm, I'm sure you'll be having that. Can you please bear with me for a few seconds and you can't really take that much time. You have to take the allergy history immediately. You have to talk about a few, you know, other medications as well and then you can prescribe, but personally, I would not suggest you to do it. Usually what happens is the patient agrees, but there are a few problematic patients. You have to convince the patient no matter what, but usually 90% of the time the patient will get convinced that ok, doctor, you can take some history and then whatever you want to talk about it, but please make it a bit quick. So you are going to take the history a bit quicker, do all the examination investigations a little bit quicker and then you jump into the management and you can take as long time as possible. You can in terms of the management. So you actually have a lot of time to manage the patient. That's a good thing. So, but yes, do not rush. Of course, you have to be very empathetic to the patient. You cannot really be robotic. Keep that in mind and keeping that in mind, you have to ask about the allergy situation as well. Ok. So after that, you have to, if this is relevant, you can ask about the family history. Ok. So is there anyone in your family with similar uh symptoms or similar, you know, um um diagnosis or something like that? So what happens is sometimes the patient himself or herself comes up with some sort of diagnosis that, you know what uh I have a sister um who has been having some sort of headache since her childhood and she has been having this headache for like uh two days, three days and it also gets triggered, you know what doctor I think this is migraine. So the patient actually, you know, leads you to the diagnosis. Sometimes please be very careful. This can be a trick as well. The patient might want to trick you to come to a certain point. Without even you asking the patient. Please do not think that I OK, I have asked a couple of questions and the patient herself is saying that this might be migraine. So this is migraine. It cannot be the case. Sometimes, sometimes you have to ask the full history to come to a certain diagnosis. So family history, very important. OK. OK. Travel history is something that is not very important in terms of all the cases. But sometimes when the patient is having some sort of, you know, uh sexually transmitted disease, you have to ask about the travel history. So having been recent traveling somewhere, OK, in terms of some uh you know, notifiable disease, malaria, anything, it can be anything. So you have to ask about the travel history in terms of that. OK. So not important in all cases, but you have to think whether it's relevant or not. OK? Just remember the structure and whichever way the this case or station is leading you to, you just uh ask the questions accordingly. If it's not important, just skip it. If it is then include it. OK. Right. Occupation. This is a, a thing that you have to ask in terms of all the psychiatry cases especially, ok, in terms of other things as well, but sometimes it is irrelevant. But in terms of the psychiatry stations, we II don't know why, but the majority of the candidates actually forget about the occupational history. So if the patient is depressed, it can be, there is a high chance it can be related to the occupation. The patient might get bullied in her or his workplace. He might say that, ok, I work in um um you know, um II do a corporate job and you know, I have recently joined it and it's been like a couple of months. I do not really get along with my colleagues and sometimes people just make fun of my lunch walks or something like that. They can be uh uh some sort of racism as well. So this is something that is very important in terms of a patient who is actually going through some phases in his or her life. So occupational history, very important in terms of psy psychiatry stations. But otherwise you can ask it if you have enough time. If you think this is relevant, you can just go for it. Ok. Right. Social history. You might want to ask the patient that, ok, do you have any friends or family or relatives uh living uh around you or do you have any anyone who has been taking care of your mental health? So social history, like how social the person is, if he is introvert or if the person is very, very so like social likes to socialize, that is very important to come to a diagnosis in terms of, again, very important in terms of the psychiatry cases as well. OK. Right after that, after you're done with this uh Mef Tosa structure, you have to make sure that there is nothing else remaining that you have missed out. So you have to ask the patient, is there anything else that I can talk about or we can talk about or is there anything else that's been concerning you? OK. So this is the maza structure. We have to follow medication, allergy, family, history, travel, history, occupation, social, anything else? OK. Not all of these are important in all the stations. We just have to think a bit and then we can include these things. OK. Right. Moving on to the next slide, right. OK. After Meza if we ask about the expectations, we can do that either we can do that before examination or after examination. So after the uh expectation question, we can we have to do the examination. OK. So if this is just a history taking station, we just have to verbalize, we don't really have to examine the patient. We don't really have to um do all the procedures and everything or something like that. We just have to verbalize that. OK. I'm going to check your vitals which is basically your pulse, blood pressure, temperature and everything else. And then I have to do a systemic examination, which is basically you don't really have to check all the systems. OK. This is something I have noticed when I was practicing back then. Um there were a few practicing partners who II used to practice with what they used to do is they did not time themselves. They used to practice by like having an, without having any sort of time and limitations. So what they used to do is they used to start from the head and, and at the toe. So what they used to do is start with the eye examination, neurological examination, checking the chest, checking the heart, checking the lungs, checking the abdominal, checking everything. You don't have that much time, ok? You just have to verbalize the relevant system. Ok? If the patient is having tummy problems, you can check the abdomen. If you, if the patient is having some sort of chest pain, you have to make sure you check the heart and lungs. Ok. So please make sure you only check the system which is related to gestation. You don't have to do all the system examination. Ok. And all these things you have to do in terms of history taking is just to verbalize. Ok. How do you know this is a combined station? You have to scan the room as we have talked about this in, in uh yesterday's session. The first thing you have to do after you enter the room is you take a quick glance and you decide whether this is a combined station or this is a history taking station. If there is a dummy, you are pretty much sure this is a combined station. Ok? So after you are done with the history taking, the patient will actually ask you uh to examine or you are actually supposed to examine the patient, which you have to pretend with a dummy, you can't touch the patient. You have to uh uh go near the dummy and then you start examining, right? So what you have to do in terms of the combined stations, when you check the dummy, you have to look at the patient's face like the simulator's space. You can't pretend that there is a head. If there is a hand or dummy or abdomen, you can't really pretend that the head is above the abdomen. You have to look at the patient's face just to make sure if the patient is having some sort of pain. If there is some sort of pain that you're causing by pressing too hard, the patient will make faces. So please make sure you check that thing. Ok? Ok. In terms of the combined stations, you actually examine the patient or Manikin. OK. There are a few stations where you actually have to examine the patient. The real patient, OK? Can be anything type two is very uncertain. So anything can come up right? So it can be a leg examination, it can be a foot ulcer. There are few station where you have to actually have to, uh, check the patient. So these are the tricky stations. I would say that you don't really know whether this is a history taking station or this is a combined station because there is no dummy, you have to examine the patient. So I would say what I used to apply is there is there is trick II used to do is I talked about the investigations. I talked about the, uh, you know, uh the examinations and everything. When I used to see that there is no results coming up from the examiner. Then I, I knew that I actually have to do those things. So I quickly, I immediately started examining the patient, but there's only few stations where you actually have to examine. So you will know that it, this is just a combined station without any dummy. So don't worry about it. Ok. Doctor S for her, if the patient is very emotional, can I touch him or her during his history taking? Ok. This is a very good question. Um I personally do not prefer doing that. Ok, no matter what. Um, for example, in my exam, what happened is there was a lady who was very old and she was having some sort of cancer and I had to break the news to her. So she was almost about to cry. And like just at looking at her, I was also about to cry. I was feeling very emotional, but I almost wanted to, you know, um touch her on her hand and I used to uh II just wanted to, you know, console her as much as I could. But what I did instead is I offered her a drink of uh a glass of water. I was like, are you all right? Do you need a tissue or do you need something else? Do you want some um water as well? Like just let me know if you need anything? Ok. So I personally do not prefer touching the patient or some people say that you can actually shake their hands before uh like right after you entered the room and introducing yourself, I personally do not prefer that because um you're not really sure how sensitive that patient is. The patient might be very religious. Uh For example, the patient might be like, ok, um II was a bit uncomfortable, please. So the thing is you don't really take the risk of touching it. If you don't touch the patient, it is, this is harmless. But if you do, there is a risk. So I would say no, this actually depends from person to person. This is just my opinion in terms of touching the patient. Ok. OK. Right. So we are done with the examination. So after we are done with the examination, we can ask about the expectation, we can ask the patient that, OK, so now that we are done with the scans, we are done with the investigations we have sent the bloods. Ok. Uh Is there anything else that is something in particular you want us to do? Is there anything specific that you want us to do for you today? So that's the thing that we have to make sure we ask the patient, which is the expectation, the one of the very important points of I ce so E stands for expectation. So we can do it either before the examination or after the examination up to you and depends on the situation, to be honest. OK. So now that we are done with the examination, the examiner will actually hand us with some sort of report or maybe scan results. Sorry, it can be a an X ray scan, it can be um some sort of, you know, investigation results. Like for example, if the patient is anemic, there will be very low level of iron, a very low level of vitamin b12 if it's a vitamin b12 deficiency. So M CV, everything else is going to be there and you have to decide whether the patient is uh actually anemic or not. So once you're done with the investigation, you um look at the examiner and the examiner will not really wait until you look at him. Uh he or she will actually hand you over the result and then you scan the result. You take a little bit of time. You can ask the patient that you know what? Um can I please have some seconds? I just have to make sure that everything is all right. Can you please give me a moment? So ask with, ask about uh the time. Ok. Uh Don't really wait for that awkward silence where you're reading the scan and the patient is actually looking at you waiting for his results to be announced. So you avoid that, you try to avoid that thing. OK? So you take a little bit of time, you verbalize that. Can you please give me a moment? I'm just gonna look at your report and I will get back to you within a few seconds. Ok? So look at the result and then you give a provisional diagnosis which is not confirmatory. You're not going to say that you are having this. You always include this word might you might be having this or you, it seems like you are having this. Ok? Please make sure you do not say that this is the thing you are having, ok? You are not 100% sure. You are not 100% sure about it. You have to double check with the senior. You have to double check with um other scans as well if you need, if you think that this is needed, so better to be safe. You don't really say that you are having this, this is for sure you are going to die. That's not how you announce the results. You have to say that you might be having this, this seems to be the problem, you know what? We have a lot of options to deal with it. Ok? So please make sure you don't say that this is confirmatory, right? OK. Moving on to the next slide. Uh this is the management part. OK. Very important, right? We have to make sure we actually follow a few steps in terms of management. OK. Before talking about the steps, I would like to talk about a few things that I have written at the side. OK. With every step of management, we have to explain why we are treating this patient this way. OK? It can be a medication, it can be uh any sort of further appointments, it can be any sort of further scans, whatever it is, we don't really do this way that you know what we're going to prescribe you this medication, you have to take it, you have to come back and we're going to see what happens. Now, you have to explain why you are treating this patient this way, why you are prescribing this medication. For example, patient is having some sort of migraine which is not being treated by any sort of painkiller. You have to explain why you are prescribing Sumatriptan. You have to tell the patient that you know what this is the medication we give in terms of long term migraines. This is going to help you with the triggers as well. You have to explain why this management is taking place so that the patient will actually be able to trust you in terms of your management plan. Ok? No matter what you have to explain, if you are referring to a specialist, you have to explain why you have to say that. OK, so you know what, we actually uh do a lot more advanced uh you know, treatment plans with the help of our seniors, which are actually specialists in terms of your condition. They are going to have a second look so that we can treat you in a better way. So you are actually explaining why you are referring this patient to a senior. OK? Keep explaining with every step. OK? If you are ordering a blood test, explain that, OK, you know what you, we have to conduct this test just to make sure that there is a certain element of your blood, the level of that element we have to check just to make sure that whether it's raised or decreased so that we can plan the treatment accordingly. Keep explaining, just trust me, this is going to make sure you your performance is 50 times better at least. OK. The approach is really good when you explain, when you keep explaining each and every step. OK? Now your question might be OK. Uh If we do not have enough time to explain each and everything, you don't have to explain each and everything. You can just summarize all of these and also summarize the explanation to each of these. You don't really have to say that, you know, um you skip step six that is provisional diagnosis. So I didn't really do that. I guess provisional diagnosis. No, I talked about this after the examination. So you have to mention that this is the provisional diagnosis. See this is uh visible, I'm sure because the slide is visible. The provisional diagnosis is something you have to mention just after examination. II think I mentioned that. So you have to explain why uh what is the diagnosis? You can't really say that this is the confirmatory diagnosis. So that's basically the provisional diagnosis. I hope I didn't skip any of the details. If I did, please make sure you also mentioned what do you want to know specifically in terms of provisional diagnosis? I will explain that. Don't worry. Ok, so where was I? OK, explaining why? Ok. You don't really have to explain each and every step. You don't have enough. If you do not have enough time, just explain uh the important things. For example, if you are treating the patient with certain medication, please explain why you are giving this medication or why you are prescribing this. Ok. If you are giving a certain investigations, just say that you know, this is the thing that we have to check. So we are giving this investigation just summarize in a very, very short like brief way. OK? You don't have to make it very vast, but please make sure if you include that this is going to sound and look very beautiful. OK, after that take consent, is that ok? Ok. After you are talking about each and every step of management, you double check with the patient that if the patient is OK with the treatment, you don't really force as II always keep repeating these things. You don't, you do not force the things to the patient. You have to make sure the patient is also OK with the management plan. So if you are talking about the uh lifestyle advices, uh for example, you are saying that OK, the patient is obese, for example. So without offending the patient about his or her weight, you could, you just say that we, you know what? You don't really have to go to the gym every day. What we can do is we can take a walk for 10 minutes or 15 minutes each day. And then we can certainly uh um start increasing that duration day by day and we can come to the point point where we actually um at least walk like 30 minutes a day. And also, you know, um sometimes the junk food can actually have a very bad effect on our health So it, in terms of uh weight, we don't really mention the weight that might be a bit offending. I might get winded as well. So, what you do is you just have to mention that, you know, um, the 30 minutes of walking and incorporating a little bit of healthy food in terms of your diet can actually help you with a better lifestyle. You will feel a bit more energetic, you'll feel like working a little bit more, you will feel less lethargic throughout the day. Uh You might not doze off in between your, you know, work uh work working hours as well. So this is how you talk about the lifestyle advices and then you'll make sure you take the consent. That is that ok with you? Do you think that you can do it? Ok. So this is how we actually take the consent from the patient. We don't really say that. Ok, how do I have your permission? Please do this? We don't take the consent this way we can say that. Ok, do you think this is something you can work on? This is how we make sure the patient is also ok, with the management plan? Ok. So these are the two things that I actually wanted to talk before talking about the uh steps of the management. OK. Any questions so far please? Um Doctor Gazel, I'm I'm not really sure which um detail I skipped in terms of provisional diagnosis. If you could just mention, please. Um, I would, I will try my best to discuss that. Ok. All right. All right. So now we are uh going to talk about the steps of management. How many steps do we have? Seven, I guess approximately. But we don't really have to make sure uh that we actually follow this, this pattern. You can just, uh you know, talk about this management steps according to your convenience. But these are the crucial steps. We don't want to miss out uh in terms of the common uh stations. OK. Uh We start with either referring or admitting if it's a hospital setting, we admit the patient. Of course, if this is a GP setting, if it's needed, we are going to refer uh if it's not needed, we are just going to talk about the symptomatic treatment. OK. That's it. So we have to keep in mind whether we have to admit or refer to the patient. So that's the first thing we have to think about whenever the patient comes to the management step. OK. We can't skip it. So what happens most of the time is the patient is having some sort of serious issues. We just give the symptomatic treatment, we just talk about the few managements. We go, we just talk about the lifestyle advisor and we completely miss out the thing that we actually had to admit the patient because this is an emergency situation. So please make sure you do not forget this step. Ok? Either admitting or referring. So it depends on the setting. If you are a GP, you have to refer if you are in the emergency department or any, any other department, hospital setting, you can mention that we are going to admit you at first. Ok. So we start the management plan by either admitting or referring. Ok. This is the first step. Ok. Second step is unless or until we are very much, we are 100% sure that this is the diagnosis. If we are not unle like 100% sure, we have to have to inform the senior. Ok. A lot of people say that. Uh OK. Why including the senior if you know that this is um a very straightforward diagnosis? Ok? Just to be on the safe side, it is a good practice to be a safe doctor rather than uh being at the risk of taking all the responsibilities of making a very, very slight mistake. So please make sure if you are not too sure you have to inform the senior. What I used to do is even this is the base, very very basic station. I still used to mention the informing the senior. Ok. It is harmless. It did. Yeah, you're not going to fail if you mentioned informing the senior. This is actually a good thing and good practice. That's it. Ok? Even when I was doing my clinical attachment I used to see the doctors, the junior doctors informing the senior no matter how basic or how harmless or how stupid the diagnosis is. They used to inform the senior no matter what. So please make sure you mention I used to prefer that, um, I would suggest to do that as well. Ok. Right after that, we have to make sure we talk about a few investigations. Either it's a blood, either it's a urine, either stool or any sort of scanning or imaging. Ok. So we can either talk about these things in terms of examination or we can talk about these things for further management in terms of uh the management steps. So the investigations, please do not forget the investigations, like, like uh most importantly, the blood examinations. Ok. So sometimes I used to forget the investigations, but this is a very crucial point. If you do not do it, you're not going to, um, get the confirmation diagnosis at the end of your um, station or consultation or maybe in the a followup um situation where you will be talking to the patient after today. Ok. So please make sure you uh mention investigation. Ok. This thing I have written in the fourth point, but I would say this is the most important thing that we, most of the time forget to mention, which is symptomatic treatment. Ok. The patient comes with headache. The patient is having the worst headache of his life. I'm talking about how the treatment is going to work. What sort of medications I'm going to give, I haven't given the patient the medication yet and I'm, I'm just talking about how the seniors are good, how, how I'm going to refer the patient immediately, but I'm not making the patient feel comfortable immediately. So please make sure you manage the patient immediately first and then you talk about the other things. You have to make sure the patient is listening to you. If the patient is not comfortable, the patient is not going to listen to you. No matter how good of the advice you're giving to the patient, it is useless unless you're treating the patient immediately. Just the symptomatic relief. Ok. So symptomatic treatment is actually given after making sure there is no allergies to the medication and there is no other medication that he or he or she is taking that is going to interact with the medication you are about to give. So, symptomatic treatment is very, very important. Ok. Ok. Next thing, lifestyle advices, very important after you're done with the medication. So basically what happens is there is actually two parts. One is the medication part part and the second one is nonmedication part. So in terms of the nonmedication part, you have to talk about a few lifestyle advisor. So you can't really be done with the medications and then you're done with the management. There are a few things that you have to make sure you mention no matter how uh you know, mainstream the treatment or diagnosis is. Even if it's like as simple as chest pain, you have to make sure you give some lifestyle advices because you have already uh talked about, um asked the patient about what sort of food habit, what sort of exercising habit he has according to his lifestyle, you are going to give the advices. Ok. There is one very important thing I have to mention. If you do not have time to make uh to talk about the lifestyle advices, all you can do is because sometimes what happens is lifestyle advises is not a single thing. It is a lot of the points, it's food, it's diet, it's walking, it's exercising, going to the gym, sleeping habit, a lot of advices, alcohol, smoking, quitting all these things. So sometimes it's like you are saying that ok, two minutes remaining, you don't really have enough time to talk about the lifestyle advises. You can just say that, ok, you know what we are going to make sure we have another appointment where we can talk about the lifestyle advices. I'm going to give to you. Is that ok with you? Ok. So that the examiner knows that, you know, there are a few lifestyle changes the patient has to make. Ok, so you rather than you skip the whole lifestyle advice thing, at least you have to mention just to be on the safe side. Ok. If you do not have enough time, if you have just go for it. Ok. Right. Specialist is specialist management is something that we already talked about, which is basically referring to the specialist, referring to the senior. Ok. So this is something we have to mention that. Ok. So there is another specialist in our hospital that is going to take care of this thing. Um, you know, I'm just giving you some symptomatic treatment and you are going to feel comfortable, but uh an expert advice is needed. So I'm going to refer you to the specialist and further uh management will be taken care of by uh by that senior of mine. Ok. So don't worry about it. Ok. So that's the specialist management. All right, after you're done with all the management steps, you have to make sure you ask the patient to follow up with you. You have to check the progress of the patient, don't you? You have to ask the patient. So you know what, after you are done with the treatment plans for a couple of months, maybe, can you please make sure that you are visiting me after a month or maybe after a week or it actually depends on the station. To be honest, if it's a chest pain, you have to make sure that you follow up with me after a week after your treatment goes on and you have to uh we have to check that whether the medicines are working or not. So following up with the doctor, you have to mention no matter what at the end. Ok? And very important because I have written this in red marks, this is safety netting. So you actually get one point just by mentioning the safety netting. If you want to mention a bit earlier about the safety netting, go for it because you cannot mess it up. Ok? If the patient is having some sort of um you know, pulmonary embolism, what I did is uh I think I was almost about to fail that station just because I didn't notice that this is actually pulmonary embolism out of anxiety. I thought this is something uh to do with the medication that he's taking. Ok, just because I mentioned the safety netting, I passed that decision thankfully. So what I did is II said that you know what if you go home, even if I was supposed to admit the patient, I said that, ok, you are supposed to go home. But if you feel that the symptoms are getting worse or if you feel at any point that you are feeling something unusual that is not supposed to happen, please make sure you call 999 or you ca come to the hospital, just make sure you reach out to us. Ok? So I mentioned the safety netting to be on the safe side. That's something that saved me from that station from failing that station. So please make sure even if you want to mention the safety netting a little bit earlier, like maybe a just after the symptomatic treatment or anywhere between the management, please make sure you at least mention the safety netting. So how do you paraphrase it? You can say that ok, anything unusual happens, any worsening of the symptoms, anything that actually makes you uncomfortable, just make sure you reach out to us. Ok, we are going to be there for you. So this is how you safety net. The patient, there is always one point for safety netting. Ok. You cannot miss that one point, right? We are done with the management. Any questions so far please? If there is no question, I'm going to move forward to the psychiatry station. Yeah. Ok. Ok. Ok. All right. Psychiatry stations very, very important, right? So there is actually a structure I always used to follow in terms of psychiatry station, which is basically, um you know, there can be a few categories of psychiatry stations. One can be depression or suicide cases. The second one can be addiction and there are a few tricky psychiatry stations which is basically psychosis or schizophrenia. So what happens there is the patient is on her or his own world? Ok. That's completely different. That's completely different. And also very interesting. I want to come up with this at the end. But then before that, I would like to uh discuss about the depression cases first because majority of the psychiatric cases are depression. Ok. So there is actually a certain structure that we can actually memorize, right? OK. You can see there are three points, right? Support psychosocial and insight. We have to include these three steps, whether it's a depression ca a case of depression or a case of suicide. But the only difference between a case of depression and a case of suicide is the two points that I have mentioned above the three points suicide. If there is a depression case, if this is a case of a person where the patient is severely depressed, you are getting the hints fro from every aspects of the patient that you know. Uh OK, doctor, you know what? I don't have good sleep. I don't feel like going out. I feel very anxious throughout the day. Um I feel very sad. I feel like, you know, giving up on everything, I feel very, very low and down these days. So you kind of know that this is a case of depression. OK. But after making sure you check all the P one P two P three, everything else you have to ask about any risk of suicide. So how do we ask about the suicide? We mentioned that as a third person, we don't say that. Do you feel like ending your life at any point? This is very wrong. This is a red flag. We can't do that. We give an example of a third person. How do we do it? We say that, you know what, I'm really sorry that you're going through all of this. And I know this is very sad and this is something that you might not want to go through throughout your life. But, uh, you know, sometimes when people feel uh this way, like the way you are feeling, they actually, um tend to feel like, you know, giving up on their life sometimes. So you have to lower your tone in terms of talking about suicide because this is a very, very sensitive issue in the UK. So when it comes to the suicide, you have to give an example of a third person, you can ask that, you know, when a person feeling feels this way, like the way you are feeling, the person sometimes wants to end their life, unfortunately. So is that something that you might be feeling lately or you have felt any time of your life at any point of your life? This is how you ask it. You will never ever confirm that thing directly that, ok, have you ever thought of ending your life to not that's an attack? Ok. That's a personal attack. The patient might feel triggered if he or she has ever felt like giving up on his life. So the person will actually get triggered and that will actually mess everything up. Ok? Um The head will be messed up. So this is very sensitive. OK. Make sure you talk about this thing as an example of a third person, right? OK. So we are talking about the depression cases at this point. OK. So in terms of depression, we talk about the suicide and then we come up with the support, psychosocial and insight. OK. What is support, support of the friends, support of the family and financial support? We ask the patient, do you have any friends that you get along with very well? Do you have any neighborhood? Do you have any family, um, members living around you or any relatives living around you or do you get along with them? Well, or do you, you know, you have a good contact with them? Do you talk to them on a regular basis? So you actually talk about the friends and family this way, which is basically the support and the one other one is the financial support. Ok. One thing about the financial support, we don't really ask directly that are you financially, you know, um, uh, you know, independent, um, or do you work? Ok. You can just ask that. Ok. Um, I am by any chance are you working currently or? Um, uh, do you don't really ask that? Ok. Uh, what job do you do? The patient might be jobless. So you have to ask from step one, which is basically, are you currently working? Ok. You don't ask that what is your job? You don't ask, um, what, what is your financial situation? You have to ask, are you working currently? Ok. So that you don't trigger the jobless person, the jobless people basically. Um, because that might be one of the major reasons why she or he is depressed. Ok. He's not finding any jobs for a very long time. So that might trigger. Yes. OK. Support. We have talked about the support. The second thing is uh sorry. The third thing is psychosocial. So psychosocial effect, how is it affected? We have to ask about the sleeping situation. We have to ask the patient that OK, um how is your sleeping habit? Are you getting enough sleep these days? Are you, is your bed comfortable? Is your environment comfortable enough for you to sleep? And um is there any issues, are you, are you getting regular sleep? Is is there anything that has been that has been interfering with your sleep these days to ask about the sleep? Because that actually affects a lot of the, you know, psychological situations? Right? After that, we talk about the concentration. Um II, have you been having some sort of difficulties these days in terms of concentrating or managing or holding up your focus in terms of uh studying or in terms of anything reading, working, gardening, anything, any issues with your concentration lately? So you asked about the concentration, which is also a psychosocial thing. OK. The next thing is mood? OK. Do you think your mood is uh like mm you there's no issues with your mood lately. So you ask the patient that can you please uh like for example, what we did in case of pain Socrates, there was a scale where we asked the patient to rate their pain in terms of the scale, right? So in terms of mood, in terms of psychiatric cases, we asked the patient to uh you know, um put their um mood in terms of the scale. So you have to ask the patient. OK, can you please rate your mood on a scale of 1 to 10, 1 being the least, uh the one being the lowest mood and 10 being the highest. So how, where do you put your mood at? So you can ask the patient about the scaling? OK. And the patient says three or four, that's severely depression. Ok. Severe depression. If the patient says 89, ok, depression might not be the case. But if it's like somewhere between five or six, you have to make sure you check a lot of other things as well. OK. All right. Right. In terms of sex, you have to ask the patient. OK. Uh Are you currently having any partners or seeing someone or are you sexually active? Because sometimes what happens is conflicts between the partners actually affects a lot on the patient's mood as well. So the psychosocial actually consists of the patient's uh sexual history, the patient's um maybe relationship status as well. So, sleeping condition, concentration, mood, and the sex life of the patient is actually which um uh which is uh which fall, which falls under the psychosocial history of the patient. Ok. Right. The fourth thing is in sight, if the patient understands that what is going on with the patient, if the patient knows enough of the patient's situation, OK. The patient might be in some other world, for example, the patient is having some sort of psychosis, the patient is um hearing different voices, seeing things, having hallucinations. So the patient might be saying that, ok, you know what I have been seeing some patient person recently. Uh this is a secret, you know, you can't really talk about this thing to any other person. So, you know, uh that person actually talks about a lot of good things I have been. Um and, and that's my new friend as well, you know, that he talks about um going to vacations, going to uh some sort of um you know, um paradise or something, but that's something you can actually get from the patient that is very, very unusual. So patient does not understand that this is actually an issue with his or her mental health. The patient does not have insight in this case, right? So we have to make sure that if the patient actually knows what is going on or not, patient might say that. Ok. You know, doctor, I think I might be having some sort of depression or, you know what I think I might be having some sort of self destructive thoughts lately. So in this case, the patient has got a good insight. So you know what, it's actually easier to deal with the patients who actually have insight of their own concerns. Ok. So please make sure that you understand whether the patient has insight or not, if they have lost their connection to the reality, this is actually something very tricky or difficult to deal with, but also very interesting as well. But please make sure you do not laugh while dealing with these patients, which is a very difficult thing to deal with. Ok. All right. So we have talked about the depression cases. Um ok, when it's depression, we have to talk about suicide support, psychosocial and insight. When this is a clear case of suicide, the patient has already taken attempts on suicide. For example, there is a case where the patient might come up with um one suicide attempt already. So this is a teenager and she has taken paracetamol like a lot of paracetamol. Uh So there is an overdose of it. So what she has done it is she is feeling guilty and she's actually very scared of death. Now and now that she is in the hospital, she's actually confronting that doctor. I'm really sorry. I have taken a lot of medications, you take a proper history first. Ok. So now that the patient has already taken attempts of suicide, we have to take a proper history of suicide. But other than that, we have to talk about her mood lately. Ok. Have you been feeling low these days? Ok. Is there any particular reason why you have been feeling low or why you have been feeling depressed or you attempted the suicide? What you did is very wrong. But is there any particular reason which triggered your thing? OK. So whenever this is a case of suicide, you have to ask, you have to ask like a lot of questions surrounding that suicide attempt. OK. So there is a proper structure to it. You have to ask that before the suicide attempt during the suicide attempt and after the suicide attempt. So you have to make sure you mentioned that is there any particular thing that you have been doing before you attempted, have written any note before you attempted the suicide? Because if she has, there is no way there is no um uh like her, she didn't really want to live. OK. So she was very, very serious about the note like the suicide attempt. OK. She was not having any will to live anymore. So this is a very severe case. So if you ask about the before situation and then the during situation in terms of suicide, that OK, where was the place you attempted? Is there and things like, is there anyone else in the house where you attempted the suicide or if there is any particular reason which actually made you decide that you want to end your life? Ok. So this is the deal situation. And after that, we have to say that, ok, so after you attempted, what was the first thing that you did? Um, and how much did you bleed if, if it's, uh, you know, cutting the risk situation and did you vomit? If she has taken the paracetamol, you have to make sure you ask about the vomiting as well. Because if she has, there might be a chance that she has already vomited all the tablets or a few of the tablets. So you, no matter what, you have to, uh, check the blood, uh, concentration of the paracetamol. But still you have to ask about the vomiting situation just to make sure that how severe the condition is. Ok. All right. The most common mistake, what we do in terms of the suicide cases is we just deal with the patient's psychiatric situation. We forget to admit the patient, we forget to test the liver function, test, kidney function test and the other test that is actually needed to treat the patient. The patient has attempted suicide. The patient is not good health wise as well. Her mental health is messed up but her physical health is also messed up. So you have to admit the patient, you have to make sure that you measure the paracetamol level in her blood, ok? And then you treat the patient accordingly, whichever antidote is needed, you have to treat the patient as well. So in terms of suicide, you have to take care of both of these things. You have to take care of the mental health. You have to take care of the medication for the treatment as well, ok? But whenever this is a suicide case, after you make sure that the patient is comfortable. If like for example, if the patient is bleeding, you have to mention that we are going to admit when you take care of the blood, we're going to be a proper bandage to your hand. And then you have to talk about the support, psychosocial, social and insight. OK? So both of these cases, depression suicide, we have to make sure we include the support psychosocial and insight. But the only difference is in terms of depression, we talk about the suicide. In terms of the suicide, we talk about the low mood like which is basically related to depression. So I hope this was clear to all of you like the structure, what we follow in terms of psychiatric cases. If this is a case of depression or suicide, OK? Just if you feel confused or if you have any questions, make sure you drop that in the chat box. OK? Right. There can be some cases where the patient can be addicted to alcohol or heroin? Ok. So there is actually a certain structure that you have to follow in terms of addiction. You have to make sure that you asked about a lot of questions. Ok. When did it start? Are you still taking it? What route you're using? Um, is there any symptoms that whenever you want to, uh, you know, uh, you want to give up on this addiction, if there, if, if there is any symptoms that you are feeling that is actually bothering you when you are trying to give up, which is a very good thing, you encourage the patient as well and then you talk about the symptoms that he has been following, which is basically a little woodrow symptoms, right? Ok. There are actually two cases in terms of the addiction, but you know, it's type two. So there can be new cases each and every day. So the most basic stations are basically alcohol and heroin addict addiction. Ok. Right. Ok. So the tricky situations are basically psychosis and schizophrenia. Ok. These patients are very interesting to deal with. Sometimes the patient comes up with some sort of insight where the patient says that, you know what doctor I am seeing these people around the house whenever it um like it's dark or sometimes I hear some voices which is basically not real. I know that these are not real and these people are not real as well, please. Help me doctor. So these patients actually have insight of what's going on with them, right? So they know what's going on, they know that something is wrong with their head, right? So they have insight, ok? Certain patients do not really have the insight. They say that, ok, doctor, I'm gonna tell you a secret, you know what? There are some people who actually meet me on a regular basis and they keep telling me that I am the queen of United Kingdom and you know what I am. So I have to go to the palace, I have to save the country and I have to take care of a lot of things. Can you please help me with that? Ok. How do you deal with these patients? You have to make sure that you do not confront these patients straight away that you know what you are wrong, there is something wrong with your head and we have to take care of you. We have to admit the patient admit you. This is not how you deal with these patients. We have to be very careful in terms of these patients. You have to be um cooperative to these patients. Whatever they say, you have to be like uh you have to be uh cooperative. You have to match your words according to their words and you have to make sure that the patient actually trusts you. If you have to make these things up. If you have to say that. Ok, you know what I can see that you are going to, you are willing to help the country, which is a very good thing. Um You know what um the country needs you as well, I II believe, yes, of course you are right. But you know what, um uh before that, we actually think that there is something wrong with your health. You don't mention whether it's mental health or physical health. You just say health so that they don't feel like they are actually crazy. You can't say that or you can't make the patients feel like they are insane. You just mentioned that. Ok, of course, I'm going to help you with that. Whatever your willingness is, whatever problems or dealings you have to deal with in terms of the country. I'm going to help you with that. But before that, can you please make sure that you bear with us for a few days, uh we are going to treat you health wise because if we do not treat you health wise, how are we going to uh take care of the country? Right? So can we please make sure that we uh take care of your health first? Because I think that um there is something going on with your health. So we are going to treat you accordingly. They are going uh we are going to prescribe you some medications and it's better if you just stay with us in the hospital so that we can talk about a lot of other things that you're concerned about and we're going to take care of you completely. Ok, so that we can make sure we can deal with the other things that you have. Um the like the other concern that you are having currently. So can you please bear with us? So you keep convincing the patient if the patient is psychotic, if the patient is having schizophrenia without insight, please make sure you bear with the patient. You do not confront that, that you know you're going through some sort of schizophrenia. This is a mental condition. You have to be admitted to the uh hospital. These are the medications you have to take for. This is the patient is going to not not going to listen to you. The patient is going to be like, ok, just forget it. Ok, I'm gonna take care of the world. I'm gonna take care of the country. Bye bye. You have to manage the patient. Ok. It's your responsibility. So these patients are very problematic to deal with. So you have to be very, very patient. You have to listen to the patient throughout the consultation and please make sure the patient does not know that does not feel like that they are crazy. Ok. So I think at the end of the session, we can actually practice the one of the psychosis uh stations if you want. If you are interested, you can just um drop a chat in the chat box so that we can, uh you know, uh practice uh one of the psychosis stations and I'm going to give you feedback as well. Like what was wrong with the stations and everything? Right. So these are basically psychiatric stations, depression, suicide addiction, and this tricky situation. These are very common. OK. Right. So I think we are almost at the end of our session today. Any questions, if there is any questions, I'm, I'm going to try my best to answer. But if there is no questions, um if you want, I can conduct some mock sessions as well. If you want to conduct, I can just send you um invite you to the stage and we can practice a few mocks if you want any of you um interested in any moocs, I'm going to be simulating. Don't worry any of you. If no one is interested, I'm just going to end the session. But if you want to, oh, that thank you so much for all your efforts on having wonderful sessions. It's completely my pleasure. My aim is to make sure that um the difficulties and the issue that I had is not something that you also face during your initial stages of preparation. Ok? If no one is interested in the mock sessions, then I'm just going to end the session within like maybe five minutes or maybe less than that. And if you're nervous in terms of mocks, don't worry, it's, it's not a professional mock. Well, uh, Doctor Bush, yes, thank you. I missed yesterday's session. Can you summarize what was it about? Ok. Uh The sessions are actually recorded in Me app. You don't really have to make sure. Sorry. So, yeah, um, yesterday's session was all about the basic structure. So, um, it's actually recorded on the app. If you want, I can send you the link to the uh um previous day's session. It was just the basic structure to be honest. Uh Like uh what are, how many stations are there? Are there? How much time do we have? And what should be the basic approach all about that? Ok. Huh. Um doctor asked if are we allowed to look for practice partners from? Of course you are, I mean, when wherever you get a practice partner, just grab them. If you want to practice, just make sure you, I just want to make sure you practice enough. OK. So if it, if, if you are going to find a practice partner from this group, please do no worries. OK. And if anyone wants to practice in today's session, it is not going to be a professional mo even if you do not have any idea, any clue of the station, that's completely fine. I'm going to guide you through it. OK? If you want, if just if you want, OK. And if you're not comfortable in video calling. You can just, we can practice through audio calls as well. That's also fine and I'm just offering if anyone is interested, we can conduct one of his practice sessions today and then we're going to end it. Are any other questions any of you? And also at the end of the session, you're going to have a feedback form. Um It would be really helpful for me to know if we need to change, make any changes to the sessions. So please make sure you actually fill out that form. It's like five or six questions, yes or no questions and that's it. Anyone wants to practice any of these stations. Uh We can do a telephone conversation if you want or we can do a psycho gestation. It is going to be interesting like you really have to be scared. You don't like we are going to learn from our mistakes, right? So anyone from today's session I can try. Ok. Yeah. Um Doctor Mom. Yeah, that's, that's a good initiative. Ok, great. So I'm gonna send you uh an invitation so that um you can join the stage, either you can try it by video uh by keeping your video on or without the video, but I would suggest to keep your video on so that um it's better, I can see your hand movements, I can see your expressions whether it's uh like, you know, if there is enough empathy or not, I can provide you a proper feedback basically. Ok. Right. Ok. I'm just going to make sure that I have this certain station in front of me. Ok. Right. Um hm just one second. I'm gonna open a case and then I'm gonna start practicing. Ok. Right. Ok. Doctor. Um have you got the invitation? I just sent you an invitation to join. Hello doctor. Uh hello doctor. No, thank you for uh allowing me the scope. Actually, this is the first time I'm going to practice. So no worries at all. No worries. Have you, have you written uh like read notes, any of the notes? Uh Yeah, like uh I started with uh going through the notes but uh so far I'm done with the history taking and examination mainly. Ok. Uh and it's really good to have some exposure to the psychiatrist administration today. Yeah. Yeah. Yeah, great or really detailed. Ok. Amazing, amazing. I'm glad to know that. Ok. So don't worry about, you know, making mistakes at all. I'm going to give like a very um you know, simple feedback at the end of the session, practice session. So, ok, I'm going to give you a stem. Uh um if you want me to write that up for you or I can just verbalize and you can, yeah, I think uh you can verbalize, verbalize. Ok, great. OK. So basically you are an fy two in psychiatry. OK. So who your patient is, Mr Alex? Ok. 23 years old brought to the hospital by the police. Ok. According to the police, he thinks that he has done something wrong. Hm. After police investigations, police found that it's a false claim. Ok. What your task is, is to talk to him and you will just have to address his concerns. Ok. Ok. I'll try. Ok. Do you have this lab to add with you or do you want me to set a timer for you? Uh I can put the stopwatch on for me. Don't worry, I have the stop. What? So whenever there is a two minutes remaining, I'm going to announce that two minute is remaining. Ok. Ok, perfect. So just a second your, so you are outside the room and you have read the stem and now your time starts now. Uh Good afternoon. Yeah, good afternoon. Oh, hi Alex. I'm Doctor Asif. I'm working as a 52 doctor in department. Uh, so how are you doing? Yeah, I'm, I'm, I'm doing good. The police are after me. Uh So what happened actually? Like uh why did the police brought you to the hospital? Do you have any idea about that? Yeah, you know what? I have committed a crime. Um Nobody really knows about this thing but I feel really guilty. I have done a terrible, terrible thing. Doctor. Um, please help me. Ok. Uh So would you mind explaining uh what actually did happen when you say you committed some crime. Um, you know what I'm, uh, I think I have harmed someone and the person, I don't think he's alive anymore. So, you know what the police came to know about it and now they are after me. Um, I just don't know what to do. Can you please save me, doctor? Ok. Uh, so where were you, uh, when the police arrived to the scene? Were you at your home or work? No, II was, I was on the road. I was walking, I was just walking. Uh And uh what did you see around you uh at the time when it was happening? Uh what was happening? Doctor? Uh like uh uh could you see people or actually you say that you h someone, uh do you have any idea who might be that person? Yeah. You know what doctor? I can't really remember what happened but I just know that I have caused harm to someone very terribly and you know, and the police are after me now. Ok. So what is the mode of harm you actually committed to that person? Like, uh you did something, uh said something bad to him or her or uh do something physically or? II think I II think I hit someone and now she's dead, I think, I think, and you know what doctor, I hear voices as well. Ok. Uh So, uh do you have these voice every time or, or, or, or uh not always, but a specific time of day or place. Always. I always, uh, hear them. I don't, I don't know what's going on, doctor. It, it's like, uh, it's been a few weeks. I just hear the voices. Ok. So what the voice tells to you, um, you know, they just keep telling me that, you know, I'm, I'm, I have done something terribly wrong. I can't really remember doing something like that, but they just keep telling me that I'm a very bad person and I think that's the reason why the police is after me. Just help me. Ok. So, uh actually did you call the police or police came to the scene on their own? The police came to the scene on my, on their own and they were, you know, walking around me. So I was feeling very guilty and, and I just went to them. I said that, you know, I, I'm not really sure what happened, but I have made a terrible crime. Ok. Uh So let's uh talk about your uh daily routine. Uh like, uh how is your sleep on a regular basis? Sleep? Um I, to be honest, I'm not being able to sleep these days. And how do you feel uh for the most of the time of the day? Um I feel terrible. Ok. Uh So does this uh vises stress you out or uh makes you anxious? Um They do sometimes. Yes. And because, you know, it's been a few weeks and they're always in my head, it feels like, you know, they are trying to put some thoughts in my head inside my head. That's the thing. Yeah, I, II think someone is plotting against me. Yes, because I'm not, I'm, I'm a very good person. So, if, if, if there is someone out there plotting against me, I wouldn't be surprised. Doctor. Ok. So, uh, as you said earlier that you hear the voices saying that you are doing something terrible. Uh Besides that, uh, you also think, uh they are inserting some thoughts into your head. So, uh can you give uh a bit detail of the kind of thoughts they are really trying to, yeah, I just told the doctor and they are trying to make me feel guilty about the crime. I'm not really sure about. They keep telling me that I'm a terrible person. Ok. All the time. Yeah. Ok. Ok. Uh And uh you were saying that, uh they are trying to harm you also and plotting against you, like, uh what do you think about that? Like, uh, do they want to, uh, do something severe? Bad? II uh I think so, you know, that's why I always carry a knife with me. Ok. Uh So actually how long you are, uh hearing these voices and carrying the knife with you, hearing the voices? Doctor? I just told you it's been a few weeks actually. Ok. Uh So is this the first time you're hearing these voices or is there any point of your life? Uh, you heard? No, this is the very first time. Ok. Uh, so Alex, uh, mm. Do you have, uh, friends or neighbors with whom you get along and go out sometimes? Two minutes waiting? Uh, no doctor. You know what? I don't have any friends and no relatives nearby. I just live on my own. I'm, I'm a very lonely person. Ok. So, uh, are you working or studying? I don't do anything. Ok. So you live alone, uh, at home? Yeah. Yes. Ok. Um, uh, so are you in any relationship or, uh, uh, involved in any social groups or activities? No, no, II, II would say I'm the loneliest person you can ever see. I'm very depressed most of the time. Ok. Uh, so sometimes, uh, uh, people hearing these kind of voices and having a feeling of, uh, inserting the thoughts into their heads, uh, think about killing someone or harming themselves on their own. So, do you ever had that kind of, uh, thoughts or ideas of harming somebody and, uh, harming yourself or harming yourself? No, no, no, no, no doctor. I can be a terrible person. I cannot hurt anyone and I cannot really think of being dead as well. So, no, never. Ok. Uh, so far we, uh, go through your, uh, complaints. Uh, I think we need to, uh, consult with the, uh, seniors in the, uh, departments. There is uh something wrong with your health but we need to sort that out and for that, we need to go for some other investigations and screening. So, are you ok with uh referring you for further uh consultation and doing some examinations? Can you please make sure the police is not after me after that? Uh uh ok. Uh that depends on how we are proceeding to the uh ways, but time is up but you can continue uh for the time being here in hospital, you will be uh under our consultation and supervision and the uh will be out of this uh total management plan. Ok. Ok. Ok. Yeah, that, that, it sounds fine. Yeah. OK. Uh So thank you Alex for sharing uh your thoughts and uh we'll work on referring you uh for further consultation. Thank you. Yeah, you're welcome. All right. See, it was not that hard. It's actually good to be honest. Um Actually, II started the management part really late a little bit and I didn't focus on few important things like inside. Yeah, insight is the, is the most important thing I forgot to include. Yeah. And definitely I forgot to uh ask about some relevant personal history like uh um alcohol or substance abuse. I think uh these two or three things I really missed out. And uh on some occasions I really miss the flow like I repeated uh I repeated the question of uh duration. Yeah. And that is almost at the middle of the conversation which might be more relevant to us or you already said that? So I don't need uh need to repeat on that. Yeah. Um That's from my part. Now, would you please share your feed? Yeah, sure. So I was actually about to ask you that. Would you be so sorry to interrupt? Like uh I was, I was uh sounding a bit monotonous and robotic and I was really failing to show the uh show the appropriate and the connection with the things. Uh though the question and phrases sounds relevant uh but the emotion was not there uh with that. OK. Yeah. OK. Yes. No, no, that's OK. Right. To be honest, for the f like for the first time, it was not that bad. I don't really feel bad about these things, but uh I just noted few things down uh just to make sure that you also know. OK, so when you enter the room, you have to make sure you talk about your name and GMC registration number. It is a good practice because that is to take at least 5 to 10 seconds of your time. Right? And then you sit down and talk to the patient. OK. So please make sure whenever you're practicing with someone, you actually incorporate that habit of uh mentioning your name and GMC registration number. OK? OK. Thank you. OK. You just pretend that there is another examiner and talking to that direction. All right. After that, I would like to mention the tone that you just mentioned, you realized on yourself that yes, you have to have some sort of empathy. You have to have, have some sort of variation in terms of tones when you're talking to the person who is actually mentally disturbed. OK. So you have to make sure the patient is feeling like you're trying to lie to the patient, right? So you have to mention that you know what sometimes I know that people might go through this sort of situations but you know what? There is nothing wrong with it and you don't have to feel scared about it. Ok? The police might be after you. But you know what, I know there is nothing wrong. So don't worry about police being after you. Ok? You have not done anything because when I mentioned the stem, it was clearly mentioned that the police confronted to you that the person came to them. But when they investigated the person didn't do any crime. Yes, it was false. So you, you assure the patient that there is nothing wrong with the patient. Ok? OK. You'll keep confirming that way the patient is going to trust you in a better way that actually maybe this is just something with my head and nothing to do with the police to be honest in reality. OK. That way you can actually bring the insight of the patient on that station sometimes. Ok. This is how it works. Ok, great. So, the reputation, yes. Uh, sometimes what we do is we try to memorize the points and then we try to cover up that silence by repeating a few questions. So if you practice for like, um, a month, it will get better. Don't worry about the reputation, it will get better with time. So just try to work on that. That's it. Ok. OK. One more thing um when a person comes to you with this sort of complaints, you have to make sure that the person knows about the present. So you ask the patient that there are a few questions that might sound a bit silly or a bit, you know, um uncommon to you, but it's just for the purpose of treatment. So do you know where you are at this point? This is what we do in terms of patients with dementia? OK. So in terms of psychiatric cases, we always ask about the patient in terms of cognition, which, which we call cognition. So where you are, do you know where you are? Do you know which location? What day is it? Uh This sound very, I'm very sorry to you, but you know what? These are very important. So this is just a part of a consultation so that we can treat you in a better way. So do you know that uh who brought you here? So we already know the police did but still we try to make sure that the patient knows that the police brought him. Ok. Yeah. And then we have a few more questions. Like, do you know that um where do you live or do you know what is your address? Just to confirm a few basic things so that we know what is the severity of the patient? Ok. Yeah, thanks. Good. Yeah, no problem. So this is how it works. And uh what I did is I tried to help you on my own. But when a person comes up with this sort of complaints, you always have to keep in mind that you have to ask about the hallucination questions. If they do not mention, you have to make sure you ask that. OK. So few, sometimes people go through conditions um like you, but what happens is they hear voices, they see people which is not basically real. So is this something that you have ever come across? Ok. OK. So you, yeah, you mentioned the hallucination questions on your own if the patient does not? OK. Because this is a very common thing in terms of these sort of psychiatric patients. Yeah, actually, like uh I was feeling uh you're helping a bit more rather than patient. And uh actually, it might be definitely more challenging to explore through that uh kind of hallucinations or deletions. Yeah. Right. Because I was uh you said that it is your first time practicing. So I just wanted to lead you throughout the consultation. Thank you. Thank you so much. Yeah, so that I can mention the points as well. You know, it's easier this way. And, um, in terms of management, uh, if you had enough time, you could say that, you know, there are a few investigations we could run and if needed, we can also talk about a few medications just if you, if you have enough time to discuss all of these. Ok. Other than that, I would say the structure was fine, just the tone and the cognition and not repeating the things again and again. And that's it. Otherwise it was a good station I would say. Thank you. Thank you. Yes, sir. No problem. No problem at all. Ok. Right. Uh, so tomorrow we are going to discuss, um, a few other stations which is basically teaching, uh, not teaching. Um, uh, just a second. So tomorrow we're going to discuss problem colleague, non accidental injury and medical error. Um, these are the ethics stations basically. So if you, if, um, doctor moment you as safe or any of you want to mention any other topics that might be helpful for you, please make sure you, um, mention that in the chat box or maybe in the whatsapp group, I can work on those. Ok. All right. I don't think anyone else is interested in the book. So I think we can call it a day, right? So this is the end. No problem. This is the end of our session. Thank you very much, Doctor Asif and thank you very much everyone else for joining. Uh, hopefully we'll be seeing you tomorrow. Ok? Yeah, thank you. All right. No problem. Bye. Thank you. All right, bye. Take care.