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Summary

This I M G T U K webinar hosted by the Widening Participation Medics Network will provide medical professionals with the tools to prepare for their plan exams and excel in UK clinical practice. Doctor Jean Marc Pair, an internal medical trainee in central London, will review common complaints and their histories, discuss safety netting, provide patient counseling scenarios, offer guidance for management, and review red flags that should alert medical professionals of the most serious health conditions. This session aims to provide the information and confidence needed to properly review complicated cases.
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Description

This session with IMG2UK and WPMN will give medical professionals an invaluable opportunity to get an insight into the nuances of clinical practice in the UK.

Join us to learn about common medical presentation and how these are managed with specific focus on systematic differences that are unique to the UK’s NHS.

Don’t miss this great chance to learn and advance your skills for working in the UK!

Learning objectives

1. Define the red flags of a headache and recognize how to assess and prioritize the top most serious conditions. 2. Understand the differential of headaches and explain common presentations of tension, migraine, and cluster headaches. 3. Identify appropriate treatment strategies for headache management and counseling to address medication overuse. 4. Recognize how to diagnose and manage a patient with acute confusion from an underlying medical condition, by taking a full history, physical exam, and obtaining a collateral history with a confusion screen. 5. Explain how to assess for neurological symptoms that can support diagnosis and management of a patient with acute confusion.
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Computer generated transcript

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

Okay. All right. Um So thanks again everyone for joining. Um Sorry for the delay. Uh This is the I M G T U K webinar that's being hosted by the Widening Participation Medics Network. And this program aims to prepare you all for the plan exams as well as for UK Clinical Practice. This series is sponsored by the Medical Protection Society, which is a, a medical indemnity provider in the UK. And today we have Doctor Jean Marc Pair who is an internal medical trainee in central London and who passed his plan exams about four years ago, I think. Yeah. So before we get started, I'd just like to remind everyone that if you have any questions at any point, just ask them in the chat. And at the end of the session will send out some feedback forms for you guys to complete if you don't mind. So I'll hand over to you now. So, yeah, so, all right. So I'm just going to start with a quick overview of what we're going to do. So I know you've got guys have had the first set of the I M T lectures. The second one is again, we're going through the same sort of common complaints going through his history, taking safety netting counseling scenarios, bit of management and some guidelines. So we're going to just start it straight off with the first case, which is a 28 year old male presented to a and a with a frontal headache, having intermittent for the last year, usually brought on by stress towards the end of the day. Sometimes responds to analgesia but not normally takes ibuprofen paracetamol every day to try and prevent them. So we can go first up with a question on what this patient should, what we should, what should you first do to manage this patient? So let you guys have a quick read and then you can decide, mm, there's only six responses so far and okay. Okay. So we'll just move on. So all of these are decent responsive, but well, let's give you a bit more information, see if you can figure out which one is the right answer. So the first thing is we should always take a full history and when you take that history, you always do a, you do a targeted history, particularly when you find the main symptoms such as headaches. So any main, any history, you take any main symptom or complaint to that patient comes up with, you should always have, you should always rule out the red flags or alarm symptoms first and that is always rule out the most detrimental, most drastic thing, the most worrying thing first and then move on with the rest of the history. So for this patient with a headache, you want to rule out some of these red flags and that would be if they have a concurrent systemic illness. And that could point you to something like a meningitis. If they have any abnormal neurological symptoms, that could point out if there's any potential for uh you know, a tumor or for something with the stroke, the onset of symptoms, the older the age and the older the age you're worried about because you would worry about something like a stroke, the progression of the symptoms. If they, if it changes with your posture, any popular edema, which suggests increased, increased intracranial pressure and any excisional provocation. So you always want to rule out red flags for any sort of complaint that a patient comes to in general. And that would be because you want to rule out the most serious thing first. All right. So a little bit of differential on these headaches, you have the main types of headaches, which is always, you know, look at what's common. You have tension, migraine and cluster headaches, you know, tension headaches or what most of us experience with bilateral band, like tightening around the head, pressing continuous for theater. Minnix resolves with analgesia. Um normally related to, you know, tiredness or caffeine withdrawal or it could be a multiple of things have caused that migraines tends to be a slightly different migraines and cluster headaches exist on a spectrum. So you have different types of migraines and you also have different types of cluster headaches. But with the most common migraine, which is an overall sort of symptom, you have unilateral bilateral, they normally have pre emptive aura which could come in the form of photophobia and phonophobia and nausea. Vomiting, not, it's not always, not, everyone will get the same sort of symptoms. They normally have this, this aura which precipitates a migraine. You have cluster headaches, which you have unilateral surveyor on the eye. And they will tell you that I have several headaches and on the side of my eyes just randomly water, nobody will ever give you these exact same symptoms all the time. But it's worth having your differential for headaches. Another another thing to be wary about is while migraines obviously do resolve with Triptan or nsaids or paracetamol, not everyone will, you know, want to Triptan or NSAID or paracetamol. So for, for when you do Klabin, um particularly in the stations, when you take a history and you real out the red flags, you don't have to be perfect at doing the management. What you should do is make sure that the patient understands what you're saying. Understand your differential of these are my differentials and you should be able to defend your differentials of X Y and Z. You don't need a perfect management plans, you just make sure the patient understands. If a, you're telling them as a simple headache or you're telling them it's a common sort of complaint, you need to make sure that they are aware of the red flags in general. So if I say this patient, you know, if this patient eventually told me their symptoms, identifies a tension headache, I would then tell them okay. It's a tension headache. Just have some allergies here for a week or two. Don't do more than that because if you have prolonged allergies and then you can get allergies, induced headaches, which you don't want. And then you want, if your headaches for your son, such as thunderclap headaches, you have any neurological symptoms, then you need to come to an E D right away and that's just sort of safety. Nothing. These patient's, yeah. All right. Uh So the other one that can cause headaches is analgesia, which is medication overuse, which allergies, a induced headaches. And it's a bit of a cycle where a lot of these patients will have a tension headache, start taking analgesia. Um, and then they continue regular analgesia for weeks on end. And it's actually the analgesia that starts causing these headaches. So then the first thing you would always do is stop the analgesia, which seems a bit counterintuitive, but actually stopping the analgesia, what resolves most of these headaches. Um And you get some with these are what counseling on medication withdrawal, symptom, it's just associated nausea, vomiting, the low BP, sleep disturbances. It's always a cluster since it's not just the headache, but they have, they feel a bit generally unwell and withdrawing simple energies here would be your first sort of target. So with case, so just to wrap up on case one come, come, they come in with the main symptom. Most important thing always rule out the red flags. If you roll out the red flags and you identify a diagnosis, tell the patient what the diagnosis is, tell them why you think the diagnosis and tell them the red flags to look out for. All right, in the history, if it's something like an allergies, India's headache, it will tell you in the history, the patient has been taking allergies every single day. You tell them for a long, you ask them for a long, sorry, the normal is three weeks on and you tell them stop that which to them might scare them, but tell them it's reassuring, stop the head, stop the energy easier. Wait for a couple of days, see what happens. And most of the time that headache will resolve, that's the case to. So 80 to your female presented to Eddie from a nursing home as they are concerned that she has been more confused recently. She has had a single temperature spike obliges. She's had an extensive medical background, including dementia type two diabetic, uh ischemic heart disease. Hypertension and af when you see her, you are unable to obtain a history due to confusion. Okay. So this is quite a common case that you will see on the take or an E D depending on what department you're in. Or even, even if you do surgery, this is something you will see because most words are elderly people. So how would you first manage this patient? Have a quick read of the question. Would you do a full, full neurological exam? If all of us they were trying to get the food, the classroom history. Admit on the jerries escalates a senior or obtain an E C G. Yeah, give people a bit more time. Fine. So I see we have a split between A and B. That's how good. All right, let's go back to the case and just have to look some more confused single temperature spike from a nursing home, a multi morbid, right? So what should we do? So this patient with an acute confusion can have many things. The confusion in the elderly is driven, driven by many things. Okay. Most of the times these patient present in in delirium and they can be a hyperactive delirium or hypoactive delirium, a potential of a lot of patient and they're different underlying causes that can drive both these things. All right, they could be, it could be sepsis, it can be a stroke and heart attack could be sort of anything that you know is that can cause any sort of illness and l they can basically cause delirium in these patient's. So it's a very nonspecific symptom to present with. Um, and you diagnosed delirium by noticing that obviously, the, the confusion disturbing inattention, you'll see they're waxing away and they'll have acute changes. Um, sometimes they'll come very sleepy and you wake them up and a bit confused and then they go back and sleep and that's a hyperactive were hyperactive. Those are the ones that try to punch you, try to climb out of the bed, try to just basically, you know, hit everyone the curse you, that's more hyperactive delirium. And sometimes you can have a big bit of both or it changes throughout the day depending. So what you can do is in a patient that comes in with confusion. Well, you know, you, you suspect it's probably delirium secondary to an underlying cause you would do a full history as you should always do do your fill um a physical exam, which would include a neurological exam because it could be anything underlying that. And then you would get a collateral history as well as doing your physical exam because you want to know a when there's this start be, was it a sudden onset of symptoms because that will then change your diagnosis and management plan? And then, you know, see, has this been happening all the time? Was it very intermittent? Because that will also change the diagnosis. And when you come in party management plan for these people with delirium is something we do something called confusion screen. And these are basically a subset of test which try to identify the most common reasons for confusion. So you do an FBC are using these and LFTs and what's in brackets there is what some of the things you try to rule out in these patient's as a differential for delirium is very, very broad. If when you do obviously your physical and you find that there is a neurological deficit, then you would be thinking more down the stroke side and you obviously end up having a CT scan. It's important to, you should definitely always try and get further collateral history because maybe they had an unwitnessed fall, maybe they had a fall and got back into bed and then became confused. It's very difficult to say. So part of your physical exam, we'll be looking for bruises, bruises or any sort of different, you know, clues as to what happened with this patient. So in addition to the blood test that you would do to rule out these underlying cause, you would also look at doing further imaging like a CT scan. If your physical exam or if collateral history suggests you do. So this is the patient extra because in addition to doing a blood test with the confusion screen, you would also do a septic screen in this patient. She's an 84 year old who's come in very confused sepsis is one of the most common reasons for this. So these blood tests including a septic screen and part of that septic screen would be a chest X ray. Um And you've noticed with these bloods, crps 100 with neutrophils lymphocytes and they right look right mid soon, right to lower zone consolidation, dense consolidation on the right side. Now, when you see this as well, on the right side, you, it makes you think about an aspiration pneumonia as well. So you would also you would look at this patient and you know, check again with your class with history hasn't been eating and drinking, okay? Are they able to swallow if then if they still confused and you wouldn't sort of give them anything to eat and drink just yet if you're worried about something like aspiration morning, but on the right side, you would be worried about aspiration. And then if you tell them, you know, keep them to their mouth, see if you can give them a trial of sips of water, see if they aspirate, we can take it from there, the patient is admitted. Um So obviously when you see all of this, see, I'll give 100 right middle. So and you would automatically start antibiotics on this patient you would cover for either you will either treat as aspiration if you suspect it or for a community acquired pneumonia. So, you would start this from the get go and then the patient's admitted to the ward and you get a bleep saying the patient is using an eight with a respirator 22 97% on room air hypertensive tachycardic and fibro. So when you see this patient, this patient is looks like septic or back to remick. So you would know your sepsis six give three, take three. So you would make sure and give them oxygen. If they're hypoxic, you would take blood cultures if not already done if you just done blood cultures. Um and you probably don't need to do some, but if they haven't done any blood cultures in E D or if not been done yet, this would be the time to do them and make sure you give antibiotics IV antibiotics. Now assuming you saw the chest X ray and those blood, you would have started IV antibiotics ready just to ensure that it's given because sometimes as patients get moved around, you don't always, people don't always get their face of antibiotics. It's always worth checking that they get their broad spectrum antibiotics depending on the trust guidelines because it does differ depending on the trust and that because they have a local subset of resistance patterns uh in, in the areas that each trust covers, you want to give up, give flu a challenge. The patient is hypertensive. So you want to give, you give a bolus, give 500 mil bolus, you don't need to give a whole litre just yet, especially in the elderly who may or may not have heart failure. And this patient, she had ischemic heart disease. So I would give 500 ola see if she's BP responsive. If she is BP responsive, then you want to give further fluid to keep that BP up if she's been confused for days on end, and she's probably not been having adequate oral intake. So you need to replace that and then you measure the urine output to ensure that the fluid you're given is enough to perfuse the kidney and then make urine okay. So, recapping case too, elderly patient comes in with confusion differentials very broad. You want to do a confusion screen because you'd want to that confusion screen, a set of blood tests which will, you know, encompass the most common things and you want to do a septic screen accepts is one of the most common reasons for delirium. That's for management wise, history wise, which I should have mentioned for is to be fair is when you see them and you can't obviously engage with them properly because they're confused. You want to get a collateral history and you want to obviously do a full neurological and physical exam depending on that collateral history. So the collateral issue is very important providing the observation to stable and then that would kind that that would guide more of your physical exam? Ok. Case three, the A T O female presented feeling very fatigued and drowsy with the last rations on her head earlier, she had an unresponsive episode where she collapse. Did the flow and beyond shaking lasting five minutes. Her clothes were soiled in urine. You sure. So what counseling advice maybe need in this now? So you read. So with that case, you're suspecting a particular diagnosis, how would you, you know, what would you need to tell this patient in the long term for long term management plan for them? You can go back to the case. So you can read, sorry, I've been going through the cases too quickly. I mean, I can leave the screen while you have the questions to pick. Okay. All right. So let's go, let's discuss this. So with this patient gives a, a, a fairly sort of classic history of a seizure, both five minutes, you know, so it depends on what at what point you're seeing this patient. Are you seeing this patient? You know, in E D while they're actively fitting? Are you seeing them on the ward while they're actively fitting? Or you now seen them in E D while they have completed having the seizure? Because depending on when you see them changes, how you will react to this patient. So I think we should start with the first one which is, you know, looking at the patient in who's actively fitting in front of you. And the first thing you should do, obviously, if somebody, if you're called to see a patient actively having a seizure, you will do your A B C D E, make sure the airways okay. Right. Give them some oxygen, check the breathing. Do they have access? Check some obs um, you know, do a quick physical and do e when you see them, if somebody hasn't started the timer, somebody should start a time on this patient or ask how long they've been having a seizure for? Okay. If they've been have, if they've started to have it for more than five minutes, then you should start giving some medications. And what you give is our first line is so vast, is quick acting benzodiazepines, which is such as IV, LORazepam. If they have IV access, if they don't have IV access, you can give Buckle Midazolam or you can even give Pr diazePAM. Um depending on the trust guidelines, but they're all options, depending on if, depending on what access this patient has. If that fails to resolve the patient, different trusts have different guidelines. But what you normally do is after you do one dose of benzodiazepine, you can normally give another dose, events of diet spine before escalating. If you find, if you need to give more than one dose of Benzo's, you should have, you should start calling your senior because you need another pair of hands and that's because you are foreseeing that this patient may need critical care input to be intubated or not. So once you give one dose and they're still seizing, you need to call for further help to give further medications. They don't at your level, they will not expect you to give IV sodium Valparaiso IV liver, Theresa tam on your own and you won't be making that decision alone and shouldn't, you would be making that with a senior and they, and as a team is what you would make, you should be able to make this decision. If you're seeing the patient after they've been seizing and you, they're stable, then the management is slightly different because then you can get a bit more history, get management plan. Is this the first, is this the first seizures? It's the second seizure. Are they on medications? Have they been taking the medications regularly? Have they're not, you know, you want to get a full medication history as well, the diagnosis of the first fit and investigation. So, assuming this is this young ladies first, I bet you'd want to in addition to take a history in addition to doing a history and physical, you'd want to have, um, uh, further investigations as to why they've had a seizure. And obviously that would be doing a full, a full blood, full, full blood test, full septic screen and the CT head and you do, the reason you do the CT head is because you want to rule out any intracranial issues that can cause a seizure, especially knee on person. You wanna do a full blood test because you want to make sure no electrolyte abnormalities can cause it on sepsis. Because a patient who's metastatic or septic can have a seizure as well. Provided all those things as they provided, all those things are negative and it is just a very seizure. Then what you should do is refer them to the first fit clinic. And that is done basically on, you would discuss with the neurology team if you have one there, but it's normally an outpatient, an outpatient um follow up that happened, happens within two weeks of there for not always within two weeks, it should be within 2 to 4 weeks, but sometimes the waiting list a bit longer. So it can happen 2 to 3 months after. And that's where they review the patient and then they decide if they want to have to start them on anti epileptic antiepileptics. You normally don't start people on anti epileptics on their first seizure. It's not what's done. Unless, unless with that first seizure, they've had pre sort of episodes where they've not quite had a seizure but had these episodes with the suggestive that they might have had a seizure. Um sort of myoclonic jerks, source of seizure activity brewing in the past. And then this is the first full blown myoclonic sort of seizure. So the main main thing of this patient is, you see them, you do all the, you do all the investigations to rule out any acute causes of the seizure. Then you then provide all last negative. You don't need to start them on anti epileptics. If and that's because first fits you normally don't. And then you refer them to the first seizure clinic as an outpatient where the the patient will be reviewed. Additional information, you to tell these patient's would be about the T V L A and not being able to drive okay, which I will go to first and come out to that um to do that, right? So all people who've had seizures need to be seizure free for about a month, a year before they can drive again. If they are category two drivers like a bus or lorry driver, then you have to be free this free for 10 years. Now, it's not your role to tell the D V L A. It is your role to tell the patient that informed the D V L A. Go back, go back. Sorry, you encourage the patient to tell the D V L A. If the patient declines to tell the D V L A, then you have to inform the D V L A. But you always tell the patient that they need to inform the D V L A to, you know, surrender their license and that's because they need to be followed up and stable and the D V L, they would normally want to have um a letter from your neurologist about your ability to drive. So let's go back to these bits. No. Um Now the reason that you give contraception advice is depending on the anti epileptics, you start for this patient. So assuming that they've had multiple seizures and you're starting antiepileptics on them, you need to give them contraception advice in general because a lot of these medications are teratogenic. So they need to genuinely be on contraception. If they are applying to have Children, then that's something to discuss with their neurologists which will alter their medications as needed. Okay. Um, all right. And then we'll go on to the next case. 47 year old female presented to GP with complaints of shortness of breath on exertion, lightheadedness and fatigue, feeling tired and sleepy all the time. She denied any night sweats, weight loss. She's known hyperthyroid antioxidant. She's sexually active with a stable partner. Okay. Just have a think of what you were the first sort of diet. What sort of things come to your head when you read this, just go to the question so you can see it and I'll come back to the case. So then you think what's your most likely diagnosis? Yeah. Uh, just good. Okay. Let's move on. So what she does, what, you know, the symptoms, all 0.21 thing which is fatigue, right? A lot of people will tell you fatigue or I feel tired and lethargic and so on. It's, it's a very nonspecific symptom and it can basically incorporate many, many things as you all know. It could mean many things, many things are going on. Very, very nonspecific symptoms of almost every single disease. It's difficult to just pin down to one thing. Right. There are different things that can, you know, clues in the history that might be able to tell you what they potentially are. But it is a very broad thing that we kind of screen for in this particular patient. What you would, what you would try to do is she tells you she's already on medication for hypothyroidism. So she's, she already complains shortness of breath, exertion, lightheadedness, fatigue, feeling tired and sleepy all the time. The first thing you want to do is check her existing medical issues and then check medications that she's taking. You want to make sure that what she's taking for her, some of her medical issues for her, you know, medical history. Oh, her current medical problems are, is optimal, which is why we talk about art. So then you would have sat so in a so other than doing, you know, so you have the nonspecific symptom, you're trying to take a history generally how long they've been feeling, you try to investigate further the existing medical problems and the medication that they're taking, ensuring that, you know, are they compliant? How they stop taking it have to run out of the medications. That would be the one of the most common things, the other, the other thing, the other things will have to come from the history itself, from the patient because it's such a broad symptom fatigue that it will just depend on what you get from the history and that, you know, other symptoms that they have. So when you take about the history, she tells you that her last minister period it days ago should normal in duration. But with menorrhagia changing 11 pads today, this has been the case for most of who your adult life, it's not felt at night before her blood showed hp of 94 MCV of 77 which is a low ferritin low ceremony and low transfer in saturation and the high TB. See, no assuming that this is, this is what she tells you. Assuming, you know, these are the blood tests you get sometimes when you are in plug and they ask, they give you these symptoms. They, you, you know, you go through history, she tells you this and then you say, you know, we do some blood tests on you. Sometimes they do hand your blood test and expect you to view to interpret. So assuming that the blood test shows you this, they might not always tell you low ferritin or lowe's ceremony and low saturation. They might just give you numbers, but it would normally be highlighted So low ferritin, normally less than 50 is what you expect. Low serum, low serum iron ceremony is very variable, are not hugely reliable, lows transfer in saturation, what you're looking for. And ideally less than 20%. So low ferritin and lower transference natural, less than 20% is what would point to something like an iron deficiency anemia and would be a common cause of fatigue in general. So cause of our deficiency anemia, multiple causes. As we all know, you could be bleeding could be uh you know, hematological issue. It could be a gut problem. It could be cancer. Though many issues, common things common. She tells you she had heavy periods, young female. So it's probably just pleading from a sort of heavy periods every month. So then when you want to treat this, if you're thinking this is the most common cause you treat with iron first, oral iron first, you don't go straight to IV. I and you go straight to your lien. And currently the guidelines were take um one iron pill three times a day, but it's changing too. I think one, every alternative is all two pills every day lines slightly changing. So just to look at, but the point is the borderline before doing IV, you don't need to know the exact dose. Just need to know you start with the oral before you give IV. You don't just go straight to IV. Unless is um a particular reason but most of the time it's gonna be something simple. The next thing is you want to control the reason that they're having iron deficiency anemia, which would be the heavy periods and the heavy periods. What you do is in multiple ways to control this. You would look at contraception first. If, if that was something that's, if that's something she would be looking at and that would be something like an IUD. Um, she can help, you know, regulate her periods from locally. You can do OCP pills which could regulate periods by regulating the hormones and then you have something like trans economic acid or meme fanatic acid, which can help with heavy periods as well. So all these are, you know, strategies to kind of alleviate heavy periods which will then treat the iron deficiency anemia, which should help with your fatigue. Ok. So just to summarize that case, so someone comes with a very, very broad symptom, think of the common things common. Look at her past medical history, look at her current medications. If she said she's taking that okay, then you look at other things, talk to her about her, you know, about her history and the history should guide you as to what tests you should order if it's still not clear what you should do blanketly and most these people is make sure and take a psych history, make sure there's no element of depression and then make sure and do a full blood test but you really electrolytes with hematinic, which would be an iron studies B 12 and folate. Uh that only that's if the sort of history doesn't quite guide you and still quite, quite, not sure. At least you have a base to start and, but fatigue is very common symptoms. Almost every disease is very nonspecific but you want to start with not, it's okay. It's five so 33 your female presented with a G P for one week ago for a blood test, sorry. After feeling tired and lethargic test written, elevated LFTs has also been having dull discomfort in the right upper quadrant, mild yellow discoloration of the eye. She has unprotected sex with her husband. 10 years frequently draws the diet of oysters and selfish several times a week. So I'll go to the question and come back to this case. What's your most likely diagnosis? This is this one's a bit tricky because in a young female, there are many, many of these things that can happen. But it's the question basically tells you a particular part of the history which which suggests the answer here. But all these options are plausible in this age group. But there's one thing in particular that should guide you. Yeah. All right, then we can move on. So it went straight to the hepatitis is. But what I would say on this, if 33 your female comes to the GP with blue blood tests, which has come jaundice, it can be many things. And in reality, what you do if this patient come to you, in addition to her telling you she had unprotected and she enjoys oysters and shellfish and oysters and shellfish. Ever. Generally sort of a red flag or, you know, like one of those things that tells you it's probably hepatitis C. Um However, in reality of this patient comes into the G B and they have a widely abnormal blood test with a high billy, high LFTs. They would go in, they would be sent to hospital and in the hospital, you would do a liver screen anyway. So you do a non invasive liver screen, which would check for the hepatitis is it would check for an autoimmune screen. The PSC and PBC, you would take a paracetamol history making sure there's no unintentional or intentional overdosing. And you would do some imaging like an ultrasound. Um just to look at the, you know, texture of the liver, make sure there's no chronic liver disease. You would look at, you know, you check for ceruloplasmin, making sure it's not Wilson's. You check for each hemochromatosis. You basically is what to call altogether a noninvasive liver screen. And it's what you do for that. You would do that for this patient. However, in this particular question, what they're trying to get you to point out is it's likely Hepatitis C because of the oyster and shelf is part of it. But this lady, she is in the right, you know, age group for PBC as well or unintentional, unintentional or intentional paracetamol over this. So these are sort of hepatitis A to E go fecal oral and then B C um uh you know, parenteral sexual IV use and then see um hepatitis Day goes with be alone. So you're going to get healthy if you have a HEP B alone. Um The hepatitis is all have different types of onset, but most have a same kind of prodrome flu like illness. John this hepatomegaly, some acute, some chronic happy and e are more acute illnesses. Uh and then don't tend to form a sort of chronic sequel whereas B and C do um you can vaccinate again. Hepatitis A and B HEP C is now treatable and then hepatitis C is a self resilient, self resolving uh issue. Let's come back and she has hepatitis B. So you would have done a hepatitis screen when she came in. Anyway, serology shows the following positive surface antigen uh negative uh anti HBs and the positive co antibody. So this suggests something. What do you think? It suggests I'm going to go back to it while this pops up. It's okay. If you don't know, we'll, we'll go a threat but there's a positive surface antigen, negative anti surface antibody anti. So this negative means is a negative anti, it's a negative anti surface antibody and it's a positive cool antibody to hepatitis B. Okay. So let's do this and we will go to, hey, and this is just general interpretation of these heavy results. So, if the patient not immune, obviously they would have a response to anything if they are vaccinated, um which you, you should have, which is the third line. You would have an anti safest antibody positivity. If you have been infected, what you would get is uh anti safest antigen positively and anti core antibody positivity. Um If it is unclear, you always get the core antibody positive. So the core antibody would be positive and acute sort of illness or in a chronic in a recent. So they're fairly acute and a sub acute sort of illness. And that's because in the sub acute when the anticort and the antique um antibody is positive, you have this window period with the surface antigen, not quite where it's not quite positively. This is so super see antibody and then the infected periods when you form the antibodies to the safest nation, which you're not yet made the safest antibodies and then the immune control, the protectors when you have the anti safest antibody positive and anti quanti body positive, which means you form the antibody but you're not actively safe as antigen positive. So there's no surface antigen positive is when they have the the actual free hepatitis floating around. So you don't have the safe Santa Gin around. So this patient would have been infected. So if this patient has a new diagnosis of hepatitis B, they would be admitted. And what you would do is you would do a Hepatitis B viral load first and then you would discuss with the hepatology team or gas routine depending on who you have. But I think what this question is trying to get you to think of as if a patient comes in with jaundice feeling and well, you need to think of, I think might be hepatitis A cancer in the stem or it can be completely different. But what what you should do is a noninvasive liver screen and look for all of them. Hepatitis is the autoimmune. Um the hereditary hemochromatosis and the world censuses which is part of the non invasive of a screen. This goes on to talk about a needle stick injury. What would you do if you have a needle stick injury? Um So it was sharp spike, scratches, flash of the blood. You do some very stayed, make sure you know, go wash out your wash out the wound, report the incident, go to occupational health and an occupational health. They will take some blood tests from you and they will guide you further when you need to take any further therapy. If you need to take split the therapy and that will depend on the blood tests you get OK. K 6 to 27% of G P requesting an HIV test one week ago, following several casual section councils in Thailand while on special understand, do he's married? Has regular unprotected sex received his test confirming he's positive HIV and is due to attend a gun clinic, he's reluctant inform his wife. So go to the question and then we will come back to the case. There we go. What's the, what is the doctor's responsibility regard in informing the wife about his possible harm? So essentially it's about this patient is very positive. Whose responsibility is it to tell the wife? It's, he also is the patient's, that's really what this is asking you. Okay. All right. So we can go through this. So these are the notifiable disease. Um in the UK, you don't need to learn all of them. So don't worry about that. What you need to know is the infectious, the, the, you know, the very infectious diseases. All of these, you don't need to worry about all of these. What you need to go to the most infectious diseases at airborne or viruses are reportable. Reportable does not mean that you are the one to break confidentiality. It just means you report to the organization and everybody will double check all the, you know, look at these before they actually reported because nobody will remember all of this. It's not how it works. So most infectious diseases are reportable. All right. So it is not a notify, this is, it's not a notifiable sees and this is why. So, oh, gosh, go back. It is current, currently considered personal data under the general protection. And the part is important, the current, what you should do is, is important for the patient, for you to inform the patient. It is their responsibility to tell their wife and for them to, uh, you know, make sure and seek out. Well, you would be the doctor giving him help for the HIV. But it's not about managing disease, about the ethics of talking about whether you disclose his HIV status. Sorry. So it's not a notify abilities and it's important to encourage him to speak to his partner. All right. This however is where it gets interesting and that's because if they, you know, it's the an intentional transmission of HIV, which is slightly different and there's a law where people can be prosecuted on there. And there are two possible offenses for this which is reckless transmission, intentional transmissions. You can only be charged if they have transmission and can be proved that they maliciously or intentionally try to give a patient HIV, which is very difficult to prove that sort of medical legal. Although what we do have in the UK is part of the notification of contact tracing. So if the patient does test positive in ST are in the gum clinic, then you have an obligation to discuss with the part of the notification. And that is a way that his wife will find out that he, that she's been in contact with an HIV pick with an HIV person and possibly has HIV. And to get tested, it is all anonymous. However, we encourage the husband or the partner, whoever to tell that to tell their, their partner first. But you have to do this anyway to a partner notification to ensure that that partner does find out. All right. And that's what this is all about. It's about essentially not breaking confidentiality, encouraging the patient to disclose is his HIV status to his wife. And you making sure that all S T I S are done reported by the part of the notification of contact tracing routes. So that in the event that um department does not disclose their status that you know, that there's still the the person they've been in contact with does find out. And that's what the importance of this is. This is just about due to confidentiality and making sure not a great confident confidentiality of a patient. And to use the most minimal necessary place and information, manage protected, be aware of your responsibilities, make sure comply by the lower, tell the patient support, the patient basically make sure be sensible. Obviously, your doctor, you know, to be confidential and all the patient's information except when the patient is a harm to themselves or others, right? This is just a quick overview of the treatment of HIV. And it's normally two N R T I s and an NRTI regimes change. And most of these pills come in, most of the triple therapies come in a single pill. Um have a whole list of side effects with these. You don't need to remem arise all of them. You just need to remember that if, when you treat HIV, there is a treatment that there's two NRTI NNRTI is that you use. Don't worry about learning all the alternative regimes and the specifics of the drugs. That's not something that you normally be asked is something that you should be able to, you know, think you're gonna this, you have first line therapy, which is two N R T I S and, and NNRTI and they should be reviewed in the HIV clinic anyway, which would monitor them and that's what you should do. You don't need, you shouldn't worry about learning all of this. You just recognize that this is what you treat HIV. With the point of this case was that about confidentiality and referring this patient and doing the part of the notification. These are the references for all of things I've spoken about. And if you have any questions, you know, thank you John Mark. And so if you have any questions, just feel free to pop them into the chat, we'll get to it. Um I've also sent out a feedback form onto the chat and if you don't mind, just please complete this for your mark, which will be helpful for him And if you've enjoyed that and you've enjoyed this series, then uh the next event will be on the 17th of June where we'll focus on uh some more medical ethics cases which can be quite heavily tested in the, uh in the Plavix. Sounds. So I'll send a link to that to sign up for the next event as well.

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