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thank you very much for coming today. Um, for those that I have met before. My name is Daniella. I'm currently my final year of medical school, and today I'm going to be giving you a talk on what the paces exam exactly entails and how you can ace your exam. Um, um, I definitely want this to be an interactive session, so I'm going to be asking you questions. If you want to put your cameras on, you can, but definitely. Please do engage. Um, when I ask questions, um, either through the chat or if you just want to amuse yourself. And, um, I will also go through the structure of the talks. So let's begin. So what I'm going to cover today? Um, I bet you're all a bit like the lady in the bottom, right? And we want you to feel confident. This is very, very important clinical skill to be able to take good histories and, of course, examine patients and come up with a differential diagnosis and appropriate management plans and be able to discuss with clinicians about your management plan, what you think is going on, So that's what we're going to do today. So we're going to discuss the structure. What exactly entails, um, how you can basically structure your history in order to get, um, relevant. Answers quite quickly from the actors were going to go through some mark cases where basically, I'm going to give you a presenting complaint. It's only giving me one for each sort of section, but But here's the time where I'd like you to interact, to give, to answer through the chat or just by commuting. And then I'm just going to give you my top tips and tricks. And then I'm just going to open the floor, too. General questions about either the paces or generally just exams or fifth year in general. This session should be less than an hour. It might be an hour, but definitely not more great. So in terms of the Pacers stations, essentially, you have eight stations, which are 15 minutes each. You have one minute reading time when you rotate one or two minutes reading time when you rotate through the stations, and there's a slight possibility that you may have arrest station now. Our paces exams occurred in the Chelsea and Western Westminster outpatients. Um, sort of units. And, um, it's quite self explanatory. You'll get a lot of details. So this is the exact stations that you will have is definitely to observe gynie to psychiatry to pediatrics and then two g P stations, which could meet a person, gain any psych or peed in a primary care setting. Now something that's quite important to mention is, especially in the GP sections. You may get mixing of the specialties, so, for instance, you might get something cycline of angina like postnatal depression. So just beware, um, and beware of stations that are not exactly like the bug standard case that you would be expecting. But I'll give more information on that as we continue. So what the actual station involves When you get in the station on the outside, you'll see the instructions, and it will sort of guide us exactly what you need to do. So follow that. But the general idea is that you take a short history 6 to 7 minutes. You ask for investigations or you're immediately given given them by the Examiner. You'll discuss the management with a patient in a layman's terms. In layman's terms, essentially, you might be asked to present the case in two sentences to the Examiner. And then you'll be asked to do sometimes discuss the management or just generally an survivor questions which could be about, um, essentially what the condition is, What's the epidemiology? Why it's important complications, risk factors, how you manage it, et cetera. And as I said before, make sure to read the instructions. They're not all the same. They don't always follow the same structure, and sometimes it might be quite worrying to sort of go from history immediately to management without receiving investigations. But that can happen. So make sure that when you practice you sort of you're confident to make a decision on your diagnosis and present the management. And some stations can be counselling stations or reviews that the reviews especially came up a lot this year. So, for instance, you might be asked to talk about the MMR vaccine with a worried patient, um, vaginal birth after C section with a pregnant lady or, for instance, a post operative review. If they've had to have emergency C section or they've had a perennial care or even a preop review for a child that needs surgery, so just make sure to be able to sort of not get thrown off even by sort of weird stations. And definitely remember, you're 80. Assessment. Um, we thought this wasn't going to come up. Turns out, for instance, I had an asthma station and there was a bit of an aide to e assessment in it, and I was slightly thrown off with that even though I could perform. I didn't know this beforehand, So that's what I'm telling you. So any questions on the structure of the Pacers station, you can, like text the chat or just a mute. Okay, I don't see any questions. I'm going to take that as you don't have any questions. Um, this is the general mark scheme. Now, I just put it in here for you guys to see, but what? It's sort of demonstrates I wouldn't be overly focused on it, but basically, what it demonstrates is that everything is sort of a global impression of how you do. Um, not it's not a tick box exercise. Even though you do need to ask specific things in the different history stations. Um, something that's very important that I'm gonna mention later is that part of your grade is dictated by what? The actor slash patient, um, thought of you. So it's very important to have good patient manner and, um, pay attention to what the patient is telling you now. As you can see, the marks came generally consists of how did they go in the history taking? Um, basically, how accurately did they summarize the findings if they give good, different chills? They came up with a management plan that's evidence based. They justify their choice of investigations, and they can communicate professionally to The Examiner were also communicating professionally, using layman's terms to a patient. So I'm now going to go over some sort of things to ask for the specific stations. So, for instance, for pediatrics, we always ask the presenting complaint the history of presenting complaint, the past medical history, drug history, allergies, family history, social history. You know this from year three? Ask it all the time to everyone if you can. Now, if it's a focused history and you don't have time to ask everything, you may skip some of these or just briefly go over them. It really depends on how important this that information is for that specific presenting complaint. What you need to always remember to ask in pediatrics is the birth history. Now can someone like just quickly text the chat? Why would birth history be important? For instance, in Pediatrics, what is something that can happen during the birth or labor anyone? It doesn't matter if you're wrong. This is good for your learning. Any injury to the infant during difficult labor? Exactly. Yeah, So that's premature. Breached pregnancy infection? Exactly. So all these things are very, very important. Because, of course, if there's any injury to the baby, it could lead. For instance, there could be hypoxic brain injury, which could then, um, lead to cerebral palsy so it would make your diagnosis slightly higher up in the Put it slightly higher up in the list of differentials. Premature babies really important, Especially if you need to do a developmental history. And you're looking at the wrong, um, milestones chart because it's not adjusted. Um, breach pregnancy. That may put you at risk of, uh, developmental displays of the hip infection. Very good candidate Meningitis, encephalitis, sepsis, etcetera. So, yeah, these are all very important things to know for the pediatric history about the labor process. Great. So developmental history Now I mentioned for cerebral palsy. Uh, an important risk. Factors having a traumatic birth. Um, can anyone give some other important things for the developmental history? What do we need to know? Just anything you'd you'd want to ask and what that could mean. Yeah, height and weight. That's very important. And asking the parent has your child be going on the same center isle? Why would you be worried if you suddenly saw a child dropping off the scent tiles? What could that be due to? There are many causes. But what What are important differentials for that malnutrition. Yeah. Great. So what What is the cause of malnutrition that you want to exclude? Say, the kid has tummy pain. Weird looking stools. Yeah, exactly. Celiac is very important. What's a social issue? That can be, um, can be a reason for dropping of Central's neglect. Exactly. Yeah, that that's really important. So information about the developmental history is extremely important about extremely important to sort of find out what's going on now. Immunizations. You're gonna have to learn the immunization schedule. Um, it is quite a last minute thing that you're going to learn, but it is very important. So, for instance, if a child is having difficulty breathing and is drooling in the mouth just looks very septic and very ill, what would be what would be something that we ask about the immunizations? Does anyone know the causative organism? It might be quite early in your placements to know this, so e B. V yeah, that is a very good one. Him awful is. Yeah. So I was thinking haemophilus influenza type B Um, exactly. Exactly. Because that can lead to, um, epiglottitis, which is a life threatening emergency. So yeah, that's very important. Um, And then, of course, classically the MMR vaccine. A lot of people think it's linked to autism. There's no evidence to suggest that. And, for instance, measles can cause this very, very fatal, um, condition called S S P, which has 100% mortality. So things like this is very important to know. I mean, these kind of cases wouldn't come up just knowing if they've had them or not. And also ask why? Because that's actually very important, because once I was taking a history from someone and the mom was was a GP, and the dad had told me that the kid hadn't had any of the vaccines, and I was just so confused and I didn't know how to act. Um, And then it turns out that when the other doctor asked, it was because the child had meningitis and just because they were so ill and immune compromised, they couldn't have had, couldn't have them. So, you know, I always ask if they haven't had them, why they haven't had them and then finally, is a social worker involved. Always ask this. Um, excuse me. I always feel awkward when I'm asking this, but I always pre face the question by saying, This may not be relevant to you, but we have to ask. Everyone is a social care social worker involved in the care of your family and just generally be curious. It's It's very important to be curious, because that's how you'll get the answers to most of your questions. So a quick, um, sort of quick fire presenting complaint So say that there's a child that's vomiting in the emergency department. Can you please just, like text the chat as to what you'd like to know from them. Um, or just a mute. What color is it exactly? So say it was bright green. What would you be worried about? Yeah, definitely. Biliary something. So essentially you can get, um, bilious vomiting with interception. You generally get bound the vomit. Um, when there's obstruction after the sphincter of oddi where the bile essentially enters the G I tracked, um, you wouldn't. Something that some people think is like, uh, they say, like billions vomiting with pyloric stenosis. No, you don't get nauseous vomiting with pyloric stenosis because the obstruction is higher than the sphincter. So you don't get billions vomiting with that. Um, okay. Say that it was white. What would you think? This is? Very common. Just white milky vomit. What is that? Not cholera know. So So it's just a child. They Sometimes after they feed, they sort of bring up white stuff. Exactly. Reflux? Yeah. Yeah, very common. Um, Gord? Exactly. Gore? Yeah. Gastroesophageal reflux. Yeah, that's very common. Great. So So any other questions you want to know about vomiting in a child? Okay. I'm gonna get some hints. So using Socrates, is there a good resource for all the presentation's. I'll get to that to the end. A judge. What? See? I be h I'm sorry. I don't know, acronym, but the the age is very important. Exactly. Change in bowel habit. Yeah, exactly. So that that is actually quite, um, Could could be hinting at something. Yeah, projectile vomit. Vomiting? Definitely. That's a sign of pyloric stenosis. Um, and that will present in sort of 6 to 8 weeks old babies. And when we say projectile, we literally mean the vomit goes to the wall. It's that projectile. Um Okay, so So something very common. What do they generally say? Vomiting is normally associated with what other symptoms most commonly. So this case that I'm just posing is not necessarily a specific diagnosis. Is just to make people think some differentials and some questions. So, yeah, it could be every time they eat. That's good. There could be something wrong with the esophagus. For instance. Um, there could be a track yourself. The official a dehydration. Very important. They may have some metabolic abnormalities that you need to correct. Stomach pain. Exactly. Are they keeping food down? Diarrhea. Exactly. Diarrhea is very important. This might just be a gastroenteritis. Food poisoning. Those are all very important differentials. Okay, Um, so I think those are very good things that you have all said. So just things that I've added, um, about foreign travel. Is anyone else ill? Any associated symptoms? Any signs of sepsis? Any other important medical problems? They may have a malformation of the GI tract, and of course it could not. It could be not linked to abdominal pain, but it could actually just be there vomiting because of signs of raised intracranial pressure. They may have the space occupying lesion. Unlikely, but just always think broad and try and just think. Why am I asking this question? It needs to be focused. What is my differential or what are my differentials? Any questions on this? Okay. I mean, that's, you know, questions. Okay, So, psychiatry again. Or classic history. Presenting complaint. History presenting complaint. Past medical history, drug history, allergies, family history, social history. Now, with regard to psych, it is quite difficult because you have to ask a lot of questions in a very short period of time. Sometimes they will extend the history time for psych to eight or nine minutes, particularly if the patient is manic, because when they're manic, they're going to be talking a lot, and you're gonna have to interrupt them. So some questions that you should always ask for psych patients, even if it's something simple, like an ADH. D you want to ask, How is the mood? Any delusions? Um, so I ask this I don't say Are you delusional? Of course. I think a good way of asking this is just saying Have you recently got any new thoughts about the world that you like to share? I think that's a good way of sort of putting it. And then any hallucinations, and if so, which senses do they involve? Does anyone know what the most common type of hallucination is? Which sense does it involve exactly? Auditory? Um, they're generally third person auditory hallucinations or persecute torrey second person. So sometimes you can you hear psych patients, particularly those with schizophrenia, that they can, um, they tell you that they can hear conversations about them, or they can hear people like chasing after them, and then they get delusional that they're being followed and they're being sort of recorded everywhere. So you definitely want to ask. Um, sort of, you might say, Do you? I know this might sound like a weird question, but have you ever found that you hear things that other people may not here? Or you see things that other people may not here and then not often open up. And then risk is the most important of the sites part of the site station. Do not forget to ask risk of harm to themselves, or is the risk to others and risk from others and the risk of suicide. If if you don't manage to get the diagnosis, at least risk assess because at the end of the day you need to be a safe doctor, and that's really important. And you can't just assume things. Compliance is a huge thing. For instance, I had this station where I was with a manic patient. This was just a mock and the patient's lithium levels. Um, the patient had a ppd and the patient's lithium levels were out of range and they were too low, and I just immediately just I just assumed that the patient was taking them and something else was going wrong. But then I understood that I was like, Oh, did I ask if they're even taking them? So ask about compliance. It's a very important question to ask, um, substance abuse. Very important. Um, you can have drug induced psychosis. Um, and even, um, just drugs that are not necessarily licit like steroids can cause psychosis, so it's very important to the past. Medical history is very relevant here. In addition to that, you want to ask about biological symptoms. Um, can someone tell me what are some biological causes of anxiety or what? What are some things you like to check before saying that this person has, for instance, generalized anxiety disorder or panic disorder? Thyroid function? Yeah, exactly. So if someone has hyperthyroidism, um, that can sort of mimic palpitations and the anxious nature that someone with a generalized anxiety disorder may feel okay. Something a bit more road, a bit. End of crying, something very rare. But can I can simulate panic disorder? It's come up on the house. Yeah. Yes. So, yeah, I feel chromosome toma. If, for instance, you you press the tumor, you may get all the adrenaline or adrenaline that's created can mimic panic disorder. Um, so, Yeah, that's very important, particularly in a patient that has very high BP. You would be thinking about that. Um And then let's let me ask you the question. So what are some biological causes of depression or low mood? Does anyone know exactly hypothyroidism? Very good. Anything else? Addison's? Yeah, I can do. I can do vitamin D deficiency. Yeah. Anything else? A bit more. Um, I don't want to give it away. Let me see if anyone gets it. Diabetes wouldn't necessarily say so, But the the having chronic don't get me wrong. Having chronic medical conditions puts you at risk of having, um, conditions like depression and anxiety and mood disorders. But I'm talking about sort of biological causes. Hypocalcaemia it can do. Yeah. Um, hypercalcemia more often does that. Um and I was just saying I was thinking, um, Cushing's syndrome. Um, and definitely. Yeah, the oral contraceptive pill. Even though supposedly, there's not much evidence on it. It's definitely a thing. So that's very important to ask people. Great. So this is good that you're thinking out of the box. You definitely want to ask, like psychiatric history. So, previous mental health disorders and also specify when you ask about family history. Be like, Do you have any medical or mental health conditions that run in the family? Because sometimes people don't think of depression as a medical problem? Um, and then I always ask about issues with the police. Um, that's very important. And it will affect their social implementation after they are discharged. If they're admitted. Great. So low mood. So say that you've got a young person that comes in with low mood. What you want to ask them. So there's no one diagnosis here. What? What would you like to know based on what we just said? Come on, guys. Someone comes in saying exactly, yeah, when the low mood started, very important. So if we're thinking depression, what's the time period? We think of drug history, anything that triggered it. Fantastic changes in appetite. Does anyone know the period of time needed to sort of categories Low mood as depression? Two weeks? Yeah, exactly. Changes in appetite. Very important. So yeah, so triggers are very important. People that have depression that is triggered are more likely to be able to be treated with cognitive behavioral therapy. Um, because there is a trigger that they can work through. Sometimes some people just experienced depression without any specific trigger and find CBT less helpful. Changes in appetite. Very important because generally with depression, it's low appetite characterized by low appetite. But you can have uncharacteristic depression with with hyperphagia so eating more and that's called atypical depression. And that's an important feature to look into. So don't always ask you about Have you been eating letters? Always ask how you have your eating habits changed. Great when the low mood started. Very important for diagnosis past medical history. Very important as well. Great. Um, anything else to say that they They had a period of depression five years ago. Would you want to know if they're coming back with low mood now? Okay, think of a practical aspect. So I'm the GP. Um, someone's coming in with a low mood, and they have a past medical history of depression that was treated with sertraline and CBT exactly CBT two years ago. All these are important question Exactly what helped them? What what was it treated compliance exactly? Because if sertraline worked for them, what am I going to prescribe something different? No, I mean to prescribe sertraline Exactly what helped them. It's very important because you don't want to send someone for endless CBT. That's not going to help them. Um, yeah, exactly. And you might also think that if the CBT didn't help them and the surgeon did, maybe I should just start them on sertraline and CBT at the same time rather than putting the CBT first and then, um, yeah, exactly. And then what did I mention? That is very important to do in the psych exam. Someone's coming with low mood. You don't know them there. Let's say at university risk Assess. Exactly. Exactly. Unfortunately, you may not think this at the time, but a lot of people are suicidal, and it's often very difficult to notice. And if someone goes and takes their own life after you've seen them, you're the last clinician that has seen them. You should you should have trouble shooting this. Um, it's very important to do that. Okay, now, this is a bit of a side note. So generally surgery in this example of an SSRI, So you give that to them. But if, for instance, that didn't work, generally What they say is that you try another drug of the same class, and then you escalate to different other different classes, like an SNRI like Venlafaxine Ventolin vaccine. There's also a drug called mirtazapine, which is an example of a NASA drug, which is very good for people that have bad sleep and lower appetite because that helps. But I always start with sertraline or, um, any of the other SSRI is This is just a side note. Yeah, so here are some examples. So when they start any triggers, if they have, um, concurrent anxiety, always ask, even though you think it's depression, make sure you ask the triad of depression, which is anhedonia the fact that you don't do things that you normally enjoy energy, which is low energy. So you feel physically exhausted to do things. And you know that's a triad, and those are the core features of depression. It's very important for you to elicit the core features of depression and then asked about sleep eating and things like that because that's how you categorize depression into mild, moderate and severe. You'll be learning more about this throughout the year, but it's very important to find out exactly what symptoms they had ever tried. Any medication, thoughts of suicide, reality. And then again, delusions and hallucinations to everyone that psych. Now, what is? I don't know if you'll know this, but what is a delusion that may present in patients with very severe depression? What is a very, very severe psychotic symptom? What do they believe? Yeah, exactly. Rotting flesh. Does anyone know what that's called? That they're rotting from the inside. So that's an example of a nihilistic delusion. Yeah, exactly, um, nihilistic delusions. So always screen for that, even if you think it's not relevant now, moving on to obstetrics, so classic history as we mentioned, and then you always want to. So basically, I separated these slides into jobs and gynie. But in Obs, you still need to ask me any questions. If it's a very focused obs history, um, let me see what I'm going to say. So, for instance, if they're coming in with abdominal pain like contractions, you're not necessarily going to be asking about them about how their periods were when they were not pregnant. But if you did have the time and if it doesn't stay focused history and you see that you do have time. Do ask about periods. Contraception S T I s etcetera, etcetera. Cervical smears. Now the old specific questions that you definitely need to ask. So when they when you first meet them, tell them I understand that you are pregnant. Can you just please clarify how many weeks along you are? Because that is extremely important in the categorization of different conditions. For instance, if it's a miscarriage, if it's a threatened miscarriage or an anti partum hemorrhage, it would be a threatened miscarriage before 24 weeks. It would be lower, part of hemorrhage if it's after 24 weeks, and then you want to know how many times they've been pregnant, which is their gravity. And then you want to know how many times they've passed the foetus, which is their parity. So parity is when the foetus that they pass. I'm saying it like this because it makes more sense. So p past, um, greater than 24 weeks. So the outcomes So let's say if they have, if they're status is G three p, too, that's probably that they've had two pregnancies that have led to to to passings, which could be still birth or live births. And then they're either currently pregnant with the three or they had a miscarriage. So you you want to ask them this because it's very important. And sometimes, for instance, the miscarriage. If they had three miscarriages, they need to be referred to a specific place to have specific tests done as to why they've had repeated miscarriages. So does anyone know a very common, very common, commonly taught condition in medical school that can lead to miscarriage is and blood clothes? Yeah, great guys. Antiphospholipid syndrome. Exactly. Okay, so then, of course, outcomes of pregnancies. So I would I would phrase this all is, if you don't mind me asking, How many times have you been pregnant or have you ever been pregnant before? And when the answer say, can you please tell me what the outcome of that pregnancy was? Okay, sorry to just stop here. There's a question. So someone saying I CD 11 energy has been taken out of the core symptoms of depression. Is it likely will be penalized for inconsistencies relating to recent changes in sight classification. So that's a great question. So we were at the point where I said 11 was introduced and we were told, told that we wouldn't be penalized because most clinicians don't know the difference is in the criteria. I would say when it comes to your site teaching, ask this button, urge you if you think about it, it doesn't really matter if you ask it. It's good if you do, because essentially it does sort of push you towards the diagnosis of depression. Um, but that's a very good point. And I can't answer. Answer it, um, with the great accuracy, because I'm not the one making the exams, but definitely ask. But my honest opinion is, I don't think it matters. So back to obstetrics. The management of the labor. Yeah, so you always want to ask them, Let's say it's, um, an anti natal clinic you want to ask them. Where were you thinking to deliver? What is it at birth center? Where you going to deliver at home and the labor would have and and, for instance, you need to ask them about. Have you thought that you might need an emergency C section what you do or how you feel or If you need a blood transfusion, are you willing to take it all? These kind of things are good questions to ask because first of all, if someone's telling you that they're generally managed by a midwife and they suddenly come to you, you're like, Oh, this is a medical medical condition. ABS Med, for instance, could be diabetes. They could have found, for instance, um, high B M. Or Or they could have found deranged results on OGTT. Um, so that's always important to ask. And, of course, if they wanted a home birth, you might have to tell them it may not be possible. Um, definitely Don't be like it's definitely not possible. But just discuss these options with them. It's very important, and this is what you would do in real life. And then I always ask if they've been pregnant. If they've. When you asked about the past medical history, tell them, Have you ever experienced any specific complications or conditions after delivery? Some women do experience postnatal depression, and it's crazy as to how many, um, mother's experience, postnatal depression and baby blues. It's very, very high number. 50% of women, I believe, have baby blues in the first 1 to 2 weeks, so that's a very high number. So it's very important for you to troubleshoot that feeding an attachment to baby is very important, particularly if there's a a social history, a significant social history involved. Um, for instance, they may often mothers that have severe depression or they might be going through purple psychosis may not be attaching well to the baby and may actually putting the baby at risk. So you want to screen for this? Um and then definitely ask the blood group in recent status. This is very important, particularly now antepartum hemorrhage if they are resistant, the negative. Um, for instance, if they're coming in for placenta previa, um, or which is painless vaginal bleeding, You may need to give them an, um, a shot of immunoglobulin against the resistance. Um, positive cells that the baby may have, um and always ask about their wishes and how they feel about the pregnancy and just always remember this, and in real life, it it doesn't matter if the pregnancy is unplanned or planned, and you should come across is very nonjudgmental and just be very supportive of the mother and their wishes. Um, and just try and not get your personal bias is involved in this consultation. This is not necessarily only for the patients station, because I think it will perform well. But this is also for real life. For instance, someone coming in for a termination, right, So on the topic. PV bleeding quick fire questions. What would you like to know? Right on the chat pain. Exactly. Pain is very important amount in any clots. Fantastic. So pain would would indicate something like, um so the pain would indicate something like placental abruption, a mountain. Any clot tells you the severity of the bleeding provoked and provoked post coital. That's very important. Because, for instance, um, if someone has a low lying placenta or something known as placenta previa, um, they are generally instructed if it's being picked up on scan to not engage in sexual intercourse. So, yeah, that's very good. And it's a very good clue. Um, and it will also guide your management so you may not do it by manual on those women, or you may not do a speculum on these women, um, relation to periods. Exactly. But say that this is in the context of the OBS. Exactly. Duration. All good questions. Great. So I've put Are you currently pregnant? How many weeks have you ever experienced a miscarriage? How are your periods? Uh, bleeding between periods or after sex? Um, any associated symptoms, like pain or abnormal discharge. So say that someone is having say that someone is having abnormal discharge and they're not pregnant. They have abnormal discharge, their bleeding between periods and after sex. Um, and just a bit of pain down below. What are we thinking? Especially in young populations. Yeah, exactly. Sexually transmitted infections, chlamydia, gonorrhea. Exactly. Um, low lying on placenta. An ultrasound scan would signify something like, um, placenta previa. As we mentioned family history of gynecological cancer, it could be that the woman is, um, is pregnant, but also had cervical cancer. So you want to ask about how their smears were before and if they've ever had any treatment for, um for for instance uh, cervical intraepithelial neoplasia. So pre cancerous lesions. Great. So on to gynecology. You had mentioned some of these. You want to ask about the periods you want to ask exactly their cycle length? If there are any regularity that might point to a diagnosis of polycystic ovarian syndrome that you need to ask, um, for instance, if they've had acne. If they have a male pattern, balding, etcetera, etcetera, Um, they might be a bit overweight, etcetera. So duration. How many days if it's very heavy? If it's associated with any pain, you might be thinking something like, um, it's I have lost it completely. Um, endometriosis. Sorry, that was it, uh, smears and any abnormal results. This, um, is really important, um, to think about cervical cancer or any other surgical pathology. To be honest, you might have a cervical ectropion, which could lead to bleeding, might have a cervical polyp fibroid. All these things are very important, and they can sometimes be seen when you do the speculum to do the smear. If they are menopausal currently, that's very important bleeding between periods after, quite as I mentioned before. If they've ever had a sexually transmitted infection either current or in the past, and if it was treated, that's very important. Um, so they say that someone told you that they come in, they are very high fever. They have excruciating lower, lower segment abdominal pain there a female, they're not currently pregnant. And, um, they have a bit of abnormal discharge green color. And they tell you that they had committee a two years ago. What would your diagnosis be? Or one of your differentials, at least? Yeah, pelvic inflammatory disease. It's very important to pick this up, and it's very important to treat it because a lot of a lot of you will know but untreated. Chlamydia and gonorrhea or P i D, um, committee and gonorrhea generally caused B I D or the cost of organisms, but they can lead to trouble scarring and infertility, and that's a very, very important complication to some women. Um, and it can also lead to sepsis, so it needs to be treated very urgently. If they're using any contraception, What type of contraception are they using? Um, also be very careful about this, Um, so just make sure you don't make any assumptions about your patients. Um, for instance, they may tell you that they're not using any barrier contraception, or they may tell you that they're not, um, that they are engaging in sexual intercourse, but they're not necessarily using barrier contraception you don't want to necessarily jump to any conclusions. It could be the same sex couple. Um, and some people, actually, I think made a mistake in the places examined. They assume that a lady, um, was with the male partner and she had a female partner. So it's very important to pick up cues and not assume anything. Um, and it's very important to be exclusive, inclusive. Sorry, um, of all patients and make them feel comfortable to talk to you. Um, that was a bit of a tangent, but on we go red flags. Um, so you always want to ask this weight loss? Bloating, irregular bleeding. Um, especially if they're postmenopausal. So So you got a postmenopausal woman. Um, coming in with bleeding. Um, and she's She had menopause at 50. And she is 52 now. What are you really worried about? And what do you need to exclude? Endometrial cancer? Exactly. And how say that the lady was was presenting with bleeding? What would you want to know? So where would you want to send the lady for further results? What does she need? Come on, guys. You've got Yes. Yes, Thank you. Trans vaginal ultrasound scan. Very important. If it's more than four millimeters, you want to send them for a biopsy. Now the criteria for premenopausal women. So women that have their periods, um, is different. The thickness is different because, of course, they will have a build up of the endometrium and shedding. So the criteria different. But focus now on post menopausal women. The the threshold for biopsy on TVA's is four millimeters thickness of the endometrium. If it's thicker than for four more, you want them. You want them to have a biopsy, and that's normally a propelled biopsy. Okay, so say that someone has dysmenorrhea so painful periods. Tell me what you want to know about them quickly on the chart. Great. So if they have heavy periods, that's very important. Um, that could lead to that. Could be something like, um, sorry, I'm just reading the chat. Has this always been the case? Regularity. Fantastic. Yeah. So endometriosis is an important differential. So just with endometriosis, the bleeding is not necessarily heavy. Um, but often in patients with endometriosis, the bleeding is heavy and painful. What sort of hints to a diagnosis of endometriosis is, um, painful periods extremely painful periods, and they can be very debilitating to the point where people can't go out. Okay, Great. I don't want to exhaust you guys, but yeah. When did you first having periods? Were they always like this? How were they? Were they always painful? Um, any pain during sex? Generally, this happens with patients with endometriosis. They complain of that as well. Sometimes if they're taking any contraception. Because, of course, things like the copper coil can cause heavy bleeding. Um, so you want to make sure there's no not a side effect of their contraception And this is actually what's going on? Sometimes some. It's like the marina coil. The hormonal progesterone coil can cause very light periods or cessation of periods as well as progesterone. Implant or injection can cause that as well. Um, and then would they be keen to try any methods of contraception for the management of they're painful periods because being on the concept of pill can sometimes help. And if they have any signs of polycystic ovarian syndrome? Great. So we're approaching the end. Um, but what I would like to say is that you don't need to know everything if something comes up and you don't know, always sort of back yourself and say I'm not really sure at the moment I would like to ask for senior advice, however, my differential zar this or I'd like to do this. Don't don't worry honestly, like you're not expected to know everything. You just need to be a safe doctor. Um, and then just a warning that the patients may be difficult. Um, for instance, if you get a manic patient, you need to know when to interrupt them in a way that also makes them feel heard. Um, and you need to learn how to deescalate situations. It's very important to master these skills and really practice the difficult scenarios. As I mentioned before, the patient's view is very important for the act of view. Um, so be friendly and in your visors make sure you structure your answers. So, for instance, if it's like a gynecological pathology and they ask you what the cause is for bleeding, for instance, you might want to split it in cervical causes. An endometrial causes other causes. Metabolic causes excess that really, really differentiates the high performers with the rest, which might be still good, but that's what sort of shows the excellent candidates, the ones that can structure their answers. You might want to say, Um, for instance, if it's like risk factors, you might want to break it up in in any way you want. Just have a structure, and that's generally very good for medicine. And then, as I mentioned, Beware station mixing. It might be a pediatric and psych history together, so it might be a 14 year old with anorexia. So just be aware about that. And then you might look at the r. C o G. Section on explaining common condition and ARBs and gynie and just be good jobs like not ob. Sorry, Dobbs, because you may have a model and you may be asked you a speculum, and you can't really tell who's done a speculum and who hasn't or, for instance, feeling the pregnant abdomen. You can tell who hasn't felt pregnant abdomen to who has with pediatrics. You should be comfortable with the ears, nose, throat, um, exam. A newborn baby checks. It may come up so generally he won't have any Children in the stations. It's generally an actor that either plays a teenager or it's like the parent that's worried and then tips on how to practice. In my opinion, I think you should join a tutor group at the beginning. Um, I believe medicine has started. This scheme is very, very important as we learn a lot from this, um and then just learn the main conditions just briefly and then just go over them and say, What can I ask? How can I distinguish this condition from the rest? Um, try to sign up to pace these marks and try to do some marks with some friends that towards the end of the year before the exams is really, really helpful. Um, and get constructive feedback from your friends, um, and then practice on real patients under time conditions. That's very important. And then I would say that also practices a pair. You may be in a group, but just do that, Um, and you may want to organize me meetings with different friends, and you can You can create your own stations and own mark schemes and virus and ask each other and test each other. That's a really good way. So you learning the condition, but and also helping your friend, um and yeah, exactly. Make your own stations. As I said, including the virus. So, um, thank you very much for listening. I really hope this was helpful. I'm not like to welcome any questions for the Pacers exam or any questions for your five. I'm really happy to help. And if anyone wants to email me at a later date, I'm more than happy to receive any emails and questions. Any questions at all? Also, please don't leave without filling in the feedback care will put the I think the link in the chat Any good resources for differentials? Um, so I think there are quite a few like BMJ. Quite a few algorithms. For instance. Robs and Janie are good to sort of choose certain, like see the differentials. I would say, um, there was this red book we had in year three. I think I can't remember the name of it. I can get back to you. Um, but generally, just like, try and make your own sort of differentials in your mind based on based on what you see. So someone's asking about the 6 to 7 minute history is they will move you on if you're running out of time, so don't be worried, but really practice in time conditions. I think that's very, very important. Um, what were the main resources you used throughout the year? So I used past mid pastors and Quest Med. I actually didn't make my own official note, um, which was quite strange, because I did that every year. But I found that you learned a lot in placement and basically past, we had pastors and Quest Med basically covered everything. And then I would definitely, like attend all the tutorials you have be be engaged in the teaching, because I think that really helps. And then when it comes to like Pace is, I use glasses, paces cases and generally, any cases that I could find on communal, um, communal banks. And I definitely I was a medic coordinator for Year five last year, so I definitely used all the lecture notes. Um, and what's it like? Took part in the lecture series. I think it's very good. So you should attend. Um, yeah, just make sure you attend things. I think that's the first thing, because even if you don't want to learn you'll passively learn. And then at some point, you'll become really good and then start remembering more things and just try and be engaged. Um, and find nice doctors to basically follow. And they'll teach you stuff Any other questions about anything at all. And please, please do fill in the feedback. I would really appreciate it from my portfolio. I'm really interested in teaching. Um, so yeah, it would really help me if you could fill it in any other questions. Don't be stressed to, like, ask me something you may not feel comfortable with. Like, this is a safe place. No problem. No worries. If there's no more questions, I'll stop the recording now. Okay, go.