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About what I think how I think it will affect the daily life and what the preventative medications are because they asked me about the acute. But I'm telling them that I'm considering that I would do it. Am I? So I still broadcasting people? So hit me. Oh, sorry. It just popped up at the top and said that I wasn't sorry. Thank you. Um Right. Oh, that really threw me. Uh Yeah. Oh, sorry. I hope I'm, I'm hoping that the, the recording is still intact, if not. Um, but, you know, I'm just waffling anyway. Um, I hope everything is all good now. Um, you all hearing me now? It's buffering at the top. I'm connected by Ethernet. What's, are we all good now? Thanks guys. Sorry. Ok. Right. We'll keep going. Um, I think that's just like the universe's way of telling me to move on. Um, professionalism bit summary of this one. Make sure you do your introductions. Um, and also don't engage other people unless you have consent for a patient. So if you have two people come in, um, so two people come in if you've got somebody who is uh maybe translating for them or if you have um a, a child and a parent um or something like that, just make sure that you speak to the person directly first and attempt to gain consent about why the other person is there. So if you've got a patient, you can just ask them. So who have you brought in with me today? Are you happy with me to talk with you with them present? If for some reason, the patient cannot communicate with you, you should still make the effort to have asked in the same way that you would in real life if you come across a patient, um you speak to them and you say, are you OK for me to talk to, to, to mum whilst you're here? And it turns out that the patient is non verbal, the the the parent is likely to answer for you and say they're nonverbal. But I have attempted to gain consent, whether the person can interact with me in a different way to uh to gain consent. That's great. Um But just make sure that you ask, don't just have people in the room, right? So like earlier, I said, conditions to consider for the acute station are simple acute histories. Look at your own revision lists that you already have. I presume and like, how long feasibly would it take to get to this diagnosis? What questions will I need to ask? What symptoms would they need to present? With therefore all of your infective travelers stuff where like you have to figure out that they went to a specific country. They had an interaction with a specific, specific insect or type of food or water. This is quite a lot of detail to also gain alongside all of the symptoms that they probably have. Therefore, malaria, for example, is an unlikely diagnosis to come up, unlikely diagnosis to come up in the other histories too, but definitely unlikely to come up in the acute history. Hopefully, that makes sense. So I've in my head, I ruled those out just like it's unlikely. I've said here, they are likely to have many easy to spot red flag flag features for conditions. The other stations also have this but these will be proper barn door things. So chest pain radiating to your left arm, unable to breathe with wheeze, these aren't going to be rare presentations of something. These will be your proper obvious stuff. I said here, unlike Pid, not trying to catch you out, sounds like a bar or M I probably is in these ones anyway. And what I mean by that is they're not trying to catch you out on the other ones, but chest pain in a diabetic patient um in the absence of arm pain, no radiation or it feels slightly different, could still be a myocardial infarction because they present with silent mis. So the actual list of conditions now that's what you're all here for here. It is why he's not loading. Ok. I have split them up into the specialties as I recommended that you do previously. And I've picked what I think are the most likely acute things to come up. I really pushed myself for some of them like ophthalmology. It would be a very, it would just be rare to get that. But if it was gonna be an OPTHO station, it was, it would be glaucoma, right? Some of these again are more rare than others. And I'm sure that if I asked you to do the same thing yourself alone with these same categories, you've probably come up with different things. But I imagine similarly, you've probably got some here that you recognize as like, yes, that's bond or really easy to do an acute history on that. And these remember are for both the sbar and the acute stations. Yeah. So hopefully these are all ones that you've I'd like to say, hopefully heard of. Um and probably already know a little bit about um yeah, depression mania psych histories challenging to do in four minutes. They know that it's challenging to do in four minutes. And remember cast your mind back to last week about when we talked about the mark schemes, the pass grade is adjusted for how you all perform. So for us, they gave us the station with a manic patient four minute history or the patient with mania. Sorry, four minute history. It's challenging. The pass mark was way lower than the other stations. Cos it was really hard not to fail because you didn't ask psychiatric risk factors. You gotta bear in mind. I love psychiatry. Psychiatry is like my big thing. I failed that, that part of the station I didn't get to the psychiatry risk factors. Despite in my head going. Don't make sure, don't forget it. Don't forget it, don't forget the psychiatric risk factors. It's just hard to do. But past the station because everything shifted cos everyone found it really hot. I hope that makes sense. Right. And the ITP one as well. A lot of people found the ITP one really hard because who knows anything about ITP. But it was adjusted down. Ok. Slides of these go up, especially feeling the feedback they sent to you. So, but I'm assuming you've all taken a picture. That's why I'm waffling on this side to allow you the time. All right. So I'm gonna move on to sbar. Now. Does anybody have any questions at this point about the stuff that we've just talked about or are we all? Ok. All doing ok. Like I said, I can see the track. So if you do have anything that pops up, continue to type it, I will see it when it pops up. Ok. So sbar, you have all have had communication skills sessions on these if you have attended them. Um This is a communication skill for handing over a patient. It is really useful in practice. And I'll be honest, the main way that I practiced ES A was not with my remember group of three friends. If, if people are still looking for three people to do that is stuff in, put in the chat to ask if anybody else is around. It is the best time to do it. Um, I practice these, not with my group of people. I practiced them whenever I was doing CBD S and Minix, it's how I present histories to people because it's the best way to practice. You do your situation, which gives them a rough top one and then the background, which is the core of your history, your assessment, which is whatever exam you did. Um And your recommendation, I'll be honest, the recommendation I kind of drop when I'm doing an SL E but in an ideal world you'd say. So I'm sort of thinking this patient might need something. Um And it will be useful to your, to your superiors as well because if they've not seen them immediately, um or they've not seen them in the in since the last shift or anything like that, you having a recommendation of just being like my recommendation is actually that they're medically fit for discharge and nothing's changed overnight. We're all good. That's reassuring for them to know. So structure situation, background assessment recommendations. This is on the piece of paper they give you, um, situation is who they are. Make sure you're talking to the right person. Otherwise that's a breach of patient confidentiality and that's her safety alert, who you are. That is both your name and the role that you currently have, who you are calling them. It is the patient name and the age and then your main concern. Why are you calling them background being? What have they come in with? What have they had before? What are the current investigation results? And what is the news including if you say a news of two, why it is two always? If you have a new score that is not zero, you should list it. Like tell me why it is not zero. Furthermore, if you've seen a news shot or like I say, if you pay attention to a news chart, BP doesn't give you an alert until it's at 100 and 80 systolic. That's quite high, right? So commonly in practice when you, when you prep notes for somebody, you'd write news zero, I would then also write the BP because a BP of 100 and 30 is much less. It's concerning with a BP of 100 and 80 right? Assessment is your main differential diagnosis and anything that you have already done. So if you've done an exam, anything like that and your recommendation, what do you want to do and what do you need them to do. Hopefully that is all similar to what you've already seen before. This is how this would come out in practice then. So hi, are you the med reg? My name is blah, blah, blah. I am the your current role of a patient. I would like some advice on. Do you have time to listen? They all say yes because there's an exam. I then also like to say, I am going to use an sbar approach. You can then also say, are you familiar with this? Um, but it just helps signpost the listener both in the exam but also in real life, what you're about to do and we give our top line like this is my patient. I'm concerned because, because you're, you're gonna be doing this because you could sit. So, so like what, what is it that's concerning to you? The background they came in, how many days ago? How many hours ago? What is their primary symptom? Do they have a past medical history? I've then said they did not have blank. And that is my main important negatives. If I've got a patient with hemoptysis, I'm then gonna say they did not have weight loss, they did not have fatigue or night sweats because I'm telling them they don't have lung cancer or I don't think they have lung cancer. Their news is blah, blah, blah, blah, blah, tell them specifically what it is and what their investigations are. If, if any have been done. Usually it's just the news chart man, I'm concerned this patient has my differential diagnosis. If you don't know, you say I'm not sure what the diagnosis is, but I'm worried or not sure what the diagnosis is, but they're deteriorating and then anything that's been given so far, that's a really useful bit of script though because it teaches you to do the differential diagnosis. And it's got an example for how do I still pass this station if I don't know what the differential diagnosis is? Yeah. And lastly, I would like you to come and review this patient as soon as possible. Is there anything I can do in the meantime, cos that's what you wanna do. You wanna make sure that they're coming because it's literally the only reason why you're referring and you wanna make sure that you, if there's something you can do that you can do it in a specific context. Hi. Are you the med Reg? My name is Devon. I'm at the fy one. I have a patient that I would like some advice on. Do you have time to listen? I'm going to use an SBAR approach. I'm concerned because they are 82 and they have worsening chest pain with hypotension in terms of their background. They came in an hour ago with symptoms of chest pain, sweating and nausea. There is a past medical history of hypertension and PVD. They did not have any dizziness loss of consciousness or resolution of their symptoms with analgesia. The news is two due to ABP of 80/60. No other investigations are available. My assessment is this patient is having an M I and nothing has been given so far. I would like you to come and review this patient as soon as possible. Is there anything I can do in the meantime? So important thing I wanna point out here is the thing that I've put in bold is that I have literally signposted the examiner to say I'm doing the background. Now I'm doing the assessment now by saying in terms of their background and my assessment is you can use it for the situation and the recommendation. I just find it really clunky to put in. Whereas the background on the assessment is good. Um li speaking to the examiners who have marked these stations, they always say that the people who say and sign post background and assessment and recommendation what they're doing score better, but it is clearer when they're getting the marks patient details, sorry in the chat, patient details outside of stations. Um The majority of the time it will say something on the outside like you're going to see Mister Brown. Um He's an 82 year old. He's coming with chest pain to the A&E take a history from him and then you'll be asked to take a form minute history and then you'll be asked to discuss your findings. Um Again, remember you're going to check with the patient when you're in there. So you're gonna double check the name. Um It's, it's fine if you forget the name, I am the sort of person who forgets the name. So if you get to the point of doing the S bar and you realize, oh, I don't know the name. You can just turn to the paper. I'm so sorry. I've just forgotten your name. What is it? And then they will just tell you below. Thank you so much. I apologize for that. And you write down, you've got the time to write it down. So if you're not sure of any details. Yeah. Yeah. Yeah. So you get given a sbar sheet of paper, you can write down the name. The problem is you don't get given the sbar until after your history. That's the challenge, right? Is you, you take your history and then afterwards sbar sheet and then you start to write it down. Um So I would write down the name. Um Did I write it on here of what I would do? No, I didn't. Sorry. Um So what I would write down is my role is a really key thing that I am often gonna forget and you only see that on the door before you walk in. Um So that there, so what's your role? I would write down the my concern and I would probably in this case write 82 low BP background. I'm writing one H chest pain, N for chest pain and nausea. I would write PM HX HTN PVD for me because I'm happy with those so hypertension, peripheral vascular disease. Um I will write down the negatives symptoms that I think are important and the news chart you will have in front of you as you're doing the sbar. But I would still write news to 80/60 because you don't want to have to be cos uh like I say, you get the news chart, you still have it when you're on the phone, but you don't wanna have to be calculating the news charts, new score and then like doing the BP at the same time, especially cos blood pressure's written annoying in the assessment approach. I would write, am I and the recommendation I probably wouldn't write anything because I am always gonna say I would like you to come and review this patient ASAP. Is there anything I can do? In the meantime, can you write down anything during the history? No. Um Unless you have a reasonable adjustment, that means that you have a notebook during your ISS naturally, then you do not have anything to write down on during the history. You can't bring in a notebook, you can't bring in any of that. Um But they will give it to you afterwards. Um Like I said though, these are, they're really simple bundle histories So like if it's an M I, they probably have chest pain and radiate into the left arm. Will, I guess that, no, but it is a lot easier to remember a four minute history than it is to remember the normal, like long histories we take on the ward. So, despite the fact that I have ADHD and the memory of a fish, I would really not worry too much about forgetting a lot of the details uh about the patient because you probably, you, you, you won't forget it. Um Has that answered your questions in the chat? Both of you if they ask you a question and you don't know the answer to it, you are just gonna tell you brilliant. You are just gonna tell them that you don't know. So like if you've forgotten their age, for example, you're probably not gonna turn to the patient and be like just whilst I'm here. Well, how old are you? Because the, the that I would ask their, their name II wouldn't ask their age and I wouldn't ask them more of the history as I'm doing it right? If they ask you, say, I don't know, I can check that with the patient if you would like and they will say no, don't worry about it because you're doing it in exam, right? Yeah. But yeah, brilliant. Any more questions? Do just keep putting in the chat? Hopefully it's useful to go to. Yeah. What was my expectation example question. Ah, yes, they ask you questions afterwards. They will ask you, what do you think is the most likely diagnosis on the phone? So this is the red asking if you've used the form that we've just discussed. You've probably answered this question already. And if you've said, you don't know, like you would say, like, I'm not sure what the diagnosis is, but I'd like you to come and review them. That's the ES A. They may still ask you at this point. I would waffle and what I mean by that is during the sbar. I would say I'm not sure my assessment is, I'm not sure of what the diagnosis is, but I would like you to come and see them urgently. Is there anything I could do? In the meantime, that's my assessment recommendation. If they then say, what do you think is the differential diagnosis? I do the same thing I would do at the end of a history or I would say I'm unsure of the diagnosis. I'm thinking it may be blah, blah, blah, but I'm not sure because of blah, blah, blah, right? That that's what I mean by waffle is that you can be, you can expound on why you are unsure. And like I said, it's ok to be wrong. Just be honest, if you're not sure what the diagnosis is, tell them that I'm not sure I am worried. Please come, please help. It is what you'll do in real life. Like, if you're presented with a case that you don't know what it is and you have no idea. You're not just gonna sit there and be, like, ah, slap some steroids on it. You're gonna ask somebody. So that's exactly what we're just practicing here. Be safe. Remember, they're looking for a good F one. They're not looking for someone who knows everything. Oops, what investigations do you want to do? Another really common one? So again, you're gonna do a similar structure to how you would do in the rest of the stations. What investigations do you want to do is very common. Consider your most likely diagnosis. So, or it's p and then pick one or two investigations that you could do quickly and tell me why. So in this specific situation here, why am I saying one or two investigations while I'm saying that because this is on the phone, they're like, what investigations do you want to do? I'm like, well, so I'm, I'm concerned that this person has a pe, um, and their BP is dropping. Um, I can see if I can get another BP done. Um, and I can see if I can organize an ultrasound point of care. D diers, they exist so I could do that. It's a respiratory condition. I could do an ABG these are quick things I can do. I'm not saying I'm gonna do an MRI that's not gonna take a, that's gonna take a while. Um I'm, I'm just thinking of the acute stuff. What could I do now if somebody's coming in with a stroke, what investigations do I wanna do? I wanna do a blood glucose and I wanna do a pulse oximeter. The stroke mimics I do wanna do a CT head, but that's probably not something I can arrange by the time that you come down and you can say that like I want to do a blood lupus. I'd like to do ap oximeter just to check for smoke stroke mimics. Um However, I'm, I'm uns and I'd like to do act head, but I won't be able to arrange that because I need you to do an urgent review. Right. Lastly, can it wait? Do I have to see them? Now? They always ask this question, they always ask it and the answer is always, please come down. Um And the majority of the time it cannot wait in an itchy scenario. So you tell them that and you tell me what you justify your answer. Um I think I've got an example working through it, but you're ba you're basically going to say unfortunately, in this situation, I don't, I don't think this can wait. I do need you to see them urgently. If you do think maybe it can wait. You can say it's not super urgent, but I am concerned and this patient I am concerned. So I would like a review as soon as possible or II think this is unsafe. This patient is deteriorating. I think I've got an example next. If it's not next, it will be in a second. So, oh, here we go. Um So what do I think is the most likely diagnosis? I think the most likely diagnosis is in the M I given the chest pain and the arm radiation, although it could be pericarditis or I'm not sure that most likely diagnosis is, but I'm worried that they're deteriorating immediately, but mostly she to get an EKG, um, I could also send off some troponin and other bloods supposed to wait for you to come down. Is there anything else you'd like me to do? Because it just means that if you've missed something, the examiner will tell you and you can say, ah, yes, can it wait? Do I have to see them? Now? Unfortunately, this patient is rapidly deteriorating and I don't think he can wait. Is there anything else I can do whilst you're on the way? And whilst this patient is stable for now, quite concerned about them. So, I'd like you to come down as soon as possible. Hopefully, it's clear that the, the ones with the two bubbles, like 12 and 12, these are separate choices for, depending on the scenario. Most likely you're gonna be doing the, the getting worse rather than this one. And I'd like to say most likely, you know what the diagnosis is, but it's good to have a script for just in case you don't. Ok. I wanna go through some example cases now, um that will sort of talk through the SBAR approach and stuff. Um But we've sort of done with the teaching part of it for now, any questions on the acute station or anything like that, we'll have a questions thing at the end. But if anyone's got anything for now, I feel like I waffle enough to answer all questions that you may, you may even think of having. Are we all good? Ok. Ok. Well, um, so, well, what I've got for this next bit, you know what, I've literally only just thought of this and I don't know why I don't think of it. I should definitely the next time that we do this, the example case bit, I'll get like a mentee up or something like that because I was like, oh, we'll just interact in the chat, but that's gonna be hard. But we'll see, um, we're going through these cases now. We've got three for us to go through um in the structure. So case number one, 24 year old MS Rodriguez attends GP with sudden onset head pain. You're a medical student running a minor illness clinic. How lucky. So this is what it would say or something similar it would say on the door. What I'm thinking when I look at this is, oh gosh, head pain. And I'm thinking of my differential diagnosis. So, just in your head by yourself now have a think those differential diagnoses head pain. Um Does anyone actually, if you want to in the chat? Tell me what, what, what would, what are you thinking? I'll tell you what I think. And when I see a symptom like this, I tend to think of something what is common and something, something, what is, I think, I think what's something common that presents with this symptom and what is like important that presents with this symptom? I remember I said last week it's common. What's important. What's a common thing that presents with head pain? Well, yeah, it's not a common one. That's sa h is my, my important one. That's the one I'm concerned about. If you've got a sudden onset of head pain, I'm concerned about subarachnoid, something common. I'm probably concerned about a headache, right? It sounds like a headache. Son in law's a head pain. This is me after one hour on a ward round, right? But concerning so right side. Yep, migraine. Here we go. I got a history for you. So you take your history and this is a good example of what I mean of a simple history because the answer is no to the majority of things. 24 year old female, severe headache started yesterday. Right sided, started at the back of the head, radiates forwards, sensitive to light. No neck stiffness. No. So that's my history. Now that we look at this history, what are we leaning towards 24 year old headache? Sensitive delight? No neck stiffness. Are we thinking more? This is a concerning subarachnoid or is this more of a headache? Yeah, migraine with oral medication. Overuse. Yep. So in this case, medication overuse, you'd wanna ask more questions about that ibuprofen. They said I occasionally, but I would say I take Ibuprofen occasionally for tension headaches, but I get tension headaches every day like so um you don't want to ask that. But yeah, I II think this history is a not concerning history. We've got a young patient, no neck stiffness, no symptoms. It does start at the head back of the head and radiate forwards, but it is unilateral. This is making me think more down the route of migraine interested in the fact that you said with aura because I'm looking at history and thinking no a because they've not told me anything like that. Um And maybe if I think, are you thinking more down the sensitive to light aspect of it? Because aura tends to present with either visual symptoms or neurological symptoms such as like tingling. For me personally, when I get migraines, I get this swirling figure, I don't even know how to describe it. It appears on the right hand side of my head that just comes into my vision like this other people that I know, get numbness in their hand. Other people just get ringing in their ears from this. For me, I'd say this is less likely to be aura. So by most likely differential diagnoses where we've just had a chat about it and we're looking down the route of more migraine. Um, so if this is an acute station, then what skills might they ask you to complete for a headache? And again, I, I'm asking you this specifically cos this is how coss I'm not gonna be here for all, all presentations ever, right? I'm gonna be here for these three and then whatever ones we do for the specialties. But you need to start thinking about, well, what would I, what might I if you're standing outside of a, a thing and it tells you head pain and you say, ooh, there's a skill behind the ski. What skill do I think it is? Yeah. Could be ophthalmology. BP also very good options. I think I agree with both of these. Um And it might seem a little bit rogue, but we're thinking in ophthalmology, if this is raised intracranial hypertension, maybe we're thinking down the route of um uh like I got glaucoma sort of picture for a fairly young. Um But yeah, BP, similar thing. It's just raised ICP. Um What else are we thinking? I agree with your BP one, right? You can literally say that they had asked you to fill in a news chart or part of a news chart for literally every presentation, blood glucose, blood glucose is a really co or low blood sugar is a really common cause of both migraines and headaches. So you can get a needle skill in there. Then I would probably think it's like, would I take venipuncture on this patient? Probably not. And I probably wouldn't cannulate this patient either. We're in a minor illness clinic. So we're really not thinking down that route anyway. But what, what would I gain from doing any of the needle skills? Not much except for blood glucose. So those are the skills that you might be asked to compete in this scenario. You could probably make arguments for other ones. But like I said, get into the habit of thinking, what could they ask me to do? What would make sense? Here's a news chart. They often give you the news chart for the sbar without it added up. So when they hand you a news chart, I would always look through and say, ah by the way that you should put numbers on not crosses, I just didn't have the space cos this is a really tiny box on the screen. Um But respiratory rate is 60 oxygen is 96% on air. BP is a 100 and 11 with no diastolic great filling on the structure. Pulse over 72%. They are alert with a normal temperature in summary, they have a new school of, oh, I think you, I just need a shot for this patient. I know you can do that. Math cos I can do that. Math. Nothing. Right. This is a healthy patient. Yeah, I agree. I agree that. So, and what I would write by the way, remember you've got this and then you're doing your assessment recommendations off on your sr she, I would write down the value. So 0123 and what the specific thing is. But this case, we're all chill. All right. So the S bar part of this, I'm not gonna ask you to write this down. But I just think in your head, how would you write this case up? I've kept, these are sp plank slides for you so that if you want to go back through, probably not this week, cos you'll remember it but like ahead of the mock or ahead of your actual ISK go through and you can write down what you do for the history that I've presented to you. You can put them in these white boxes here. So how, what would I write? And I've kept it really simple for what I would physically write in the exam I would write. So II wanna call the GP, I'm in minor illness clinic in GP. So I wanna speak to my GP. I've got a 24 year old with query migraine. What's the history, unilateral throbbing headache started yesterday, photophobia and nausea, no neck stiffness, no rash. News of zero, my assessment is that is a query migraine. My recommendation is review and then I add in may need so atrip or other analgesia because that's my thought of that. She's got an ongoing migraine. That's what we made to do. Hopefully that is all similar to what you'd be thinking to write down if anyone has any comments by the way or thinks I've missed something. Do let me know um, before they ask you, what do you think the most likely diagnosis is? So in this situation, we said this is a migraine, we most likely um due to a unilateral throbbing headache. And then I said, we may need to rule out a subarachnoid hemorrhage, but it is unlikely. And I think hopefully we're all in agreement. This doesn't really seem like an SA H especially with no past medical history. What investigations do you want to do? We sort of answered that when we're thinking about the skills but migraines a clinical diagnosis, no immediate things that we need to do here, but blood sugar may be useful and imaging down the line. So we do investigate new onset headaches and I'll see. Can it wait? Do I have to see them now? What do we think for this one? Can this patient with query? Migraine? Wait. Yes or no. Yeah, it can wait. Like we don't need to see this one. Now. Um Yeah, patient's stable. It can wait but she is in pain and I would probably wanna say that it's like she does need a review. She's in pain. She needs a diagnosis and I can't give her anything. I'm a medical student. Yeah. Um so yeah, this situation. Yeah, patient is stable. If anyone has any questions or comments on the case, you just put that in the chat and I will address if not, we have 56 year old Mr Vinda attending A&E with hemoptysis and chest pain. We are an fy one who reviews him. So I'm thinking before I even see this patient cos I'm standing outside that door thinking what hemoptysis, chest pain. What am I thinking for this patient? Remember they do present with those nice bond or things. So just think to yourself, what will I think in this case? 56 year old, I just a bit the history itself. You'd go away and do it obviously. But they are a 56 year old male with sudden onset chest pain that started yesterday. Sharp pain, left hand side started at rest hasn't stopped. Worse on inspiration. Never had anything like this before. Have got clear sputum, but they've got streaks of blood in it with about a cup in the past 24 hours. No past medical history, no drug history returned from holiday two days ago and he is concerned because he has to take further time off work cos he's unwell. So, what are my differential diagnosis diagnoses for this patient? What am I thinking that I will make a thing for next time? But what do you think that is under your? I hope I can do a mentee. I agree. Do you see what I mean by? It? Certainly could be both of those things. So, these are, I would put them probably as my secondary things and atypical pneumonia. Why am I thinking that? Well, we've not said about crackles or anything yet, but we've got a cough and we've got blood. So we're like, well, this could be an infection, certainly pericarditis. We've got an inspiratory chest pain. Yeah. Um, uh, yes. Um, so both of these things I think are entirely valid diagnoses in this situation here. Um, what was I saying? I got distracted. Um, oh, hopefully it's clear what I mean, bond or presentations, right? These are really like, they really point towards the diagnosis. TB is definitely another one. the thing is with the T B1 here is that like you've got like this travel history, um, which is like, could be pointing towards, oh, they've been on an airplane or could be pointing to, oh, they may be, may have been to an area that is endeavor to, to TB or another infection. Yeah. Um, also pneumonia also being a flying tin can, that is a nice incubation area for infection, isn't it? Um, yeah. So all entirely valid diagnoses. Yeah. Um, differential diagnosis there. That's what we're talking about. Um, what skills might they ask you to complete in this patient? I remember to answer this question. We think, well, what's my main differential diagnosis? And I'm gonna go from there. So what do we think? Investigations? And again, it's more important that you think about it for yourself than for us. E CG is a brilliant one. E CG is a really good example of something that you'd wanna do in this case. Um And it's a skill that you can do in four minutes. Um Well, score, you would definitely wanna include that in terms of di in investigations, like when you do your sbar stuff, like I would want to carry out a well score. Um, but well score isn't a skill, a clinical skill that you need to carry out, but it's definitely worth thinking about E CG or ABG. Yep, you could do an ABG here. Um, remember basically it's probably a bit reductive, but when I think, do I need to do an ABG in this patient, I'm thinking, does this patient have a condition which may affect their ability to breathe or get oxygen to their tissues, which is any lung things and also any circulatory things that are affecting the lungs? Um Yeah, so then bloods and D Diers. Yeah. So I would need to do ad dimer in this case. How would I do that? I would take a blood. So the skill that they may need to be getting you to do is can you do venipuncture on this patient? Yeah. Um And so you can sort and obviously we talked about a new score, you do a new score on anybody. Um But yeah, certainly these are all skills that are likely to do and like I said, getting into the habit of thinking about it, so you can prepare for that skill early and thinking about where you can link it in is useful for both preparing outside the EK station. But you've all just pointed all those things out about what they might ask us to do, which I hope helps in your head. Link together. The fact that when somebody presents with something that looks like maybe a pe that I need to be doing an E CgA well score, maybe an ABG and some blood. Yeah. So it sort of, it all helps smush together. Cool. All right. So news chart, what have we got then we've got a third. So again, read through. So this is the news chart for person's name taken today at the time. 13 respiratory rate over 96% oxygen, um er oxygen saturations. This one here, they're on oxygen and I've written here annually. So that's me, me, me saying they're on nasal cannula, um BP here. Um pulse all the way through. What's the new score for this patient? Another way of phrasing. It is when you look at this, um is this an is this an unworldly patient? Yeah, I agree. And this patient is scoring a three. And again, when we are about to write that down on our, in our, our sbar sheet, we're gonna say why. And this patient is scoring a three cos they've got two because they're on oxygen receiving any amount of oxygen. Automatic two. And then, yeah, like you said in chat, we've got a tachycardic patient and tachycardic in this light yellow, the yellow 12 plus 13. Reassuringly in terms of our other diagnoses like the pneumonia and the TB and stuff fever. No. Yeah, BP is nice. Ok? Um So use us three. So again, this sheet here is for you to have a practice at doing it yourself. Have a little think. Now what would you put in these different bits? I'm gonna show you it very shortly anyway. Uh Why do I keep going blurry? Mm um So what I, what would I write down in this situation? I need the med reg in this case cos I'm in a hospital, 36 year old male concerned as query p um background left sharp pleur chest pain, hemoptysis just had a long haul flight. I know that I didn't say in the history that it was a flight specifically but like that's what you would ask about. No past medical history or other symptoms. Not a smoker news three due to oxygen and tachy. At one term assessment is a pe recommendations p review. Anything I can do. It's a nice little rhyme. This one here as a case does have a sneaky aspect to it. And it's the fact that, that the, unless you explicitly asked about um travel history, this patient would not have told you that they had originally come back from holiday. So unless you explicitly asked any recent travel or if you had asked their ideas, concerns and expectations. So, remember, this patient was concerned and they were concerned because they'd just taken time off for a holiday and they're now having to take time off sick and then you go. Ooh, where have you been? Well, you're on an airplane, right? So sometimes they'll be sneaky. There are lots of stuff in histories that you are that the actors are told not to tell you unless you are asked directly. It's just bad. I might, how will we answer this question? Then? Most likely diagnosis? We've talked through this already. I think this is apa, um, due to inspiratory chest pain and hemoptysis. I've said I'd like to rule out an M I, you can also talk about any of the other things that we've talked about. So I'd like to rule out pericarditis, uh, pneumonia, um, TB, any of the other things. What investigations do you want to do? Well, we talked through a lot of them already and remember in this case, we're talking about the ones that we can do quickly. I want to do an E CGI wanna do AD dimer and I want to do an ABG E CG because I'm looking at for pe stuff D dimer cos I'm looking for a clot, ABG because it's affecting the oxygenation of the blood. That's my thought process for it is what I'm explaining. Um Can it wait? Do I have to see them now? What are we a for this one? Can it wait? I know that asking for you for? Yes or no is very reductive. Cos in real life you'd be like, mm, like depends on the clinical picture of the patient. But if you were gonna come down, can it wait or do we have to see them now? And if you argued it either way, as long as you justify your answer, either of these are actually correct. I'm just curious what you guys think. Is there perhaps something that you would have in an sbar station that would tell you whether it can away or not. You don't have to answer that to me. You can do. I would love it. But yeah, the news chart. Right. If you get a news chart you turn it over. Yeah. Back of the news chart. Exactly back of the news chart tells you when you should be concerned. I'll be honest. I don't know. I don't know the exact cut offs. I'm pretty sure. I think it's like if it's more than two, then you should be checking with somebody and then more than three is this is a big issue. This person's got a, a news of three and in the thing, I would turn it over and I would just double check and it would say um but in my mind, if you're scoring a two, I'm worried about you. If you're scoring a three, somebody's coming now. Yeah. Um So I would say now this patient is stable for now, but I am quite concerned about them. They've got that news of three. You need to come down as soon as possible. Why is this patient stable? This patient is stable because their BP and their heart rate is stable, not actually deteriorating and they're not bleeding to this. All right case three. Then a 35 year old Mr Thompson brought it into the emergency department unconscious. You the fy two this time, take a collateral history from his partner. Remember to establish the relationship of the person you're taking the history to, to the partner. So it says on the door, it's a partner. But as you go in, you want to make sure that you ask the partner. Um So I'm here to talk about Mr Thompson. Can I just confirm what's your name and what's your relationship to Mr Thompson again? You're outside the door. You have a few minutes, you can think. Well, 35 year old coming unconscious. What am I thinking? And I've not given you any history so far, but this is something that would probably throw me a little bit uh because causes of unconsciousness are abroad and we don't even, we don't know if this patient has had any kind of trauma or anything like that. Um But try and think, I know the sort of things that I'd be thinking about right now, but I don't wanna spoil the case. So let's have a look patient, 35 year old male presenting with a loss of loss, loss, loss of consciousness, abdo pain and confusion. Partner reports that he's become increasingly tired over the past 3 to 4 days with worsening generalized abdominal pain. He's not eating due to the pain, he's drinking more water than normal. It's a past history of type one diabetes managed with insulin. He's been off the insulin for the past few days because of the pain. So he's not, he's not eating. So he's not taking his insulin. Never had anything like this before. Um, and they're unsure of what his, um, bowel movements are like and unsure if he's been uh urinating recently because it's the partner we're taking collateral history. Sometimes they just don't know. This is probably the hardest case of the three that we talked about today just because I think sometimes it's just a bit of a blind spot for people. What were we thinking? What are differential diagnoses with this DK A, we've got a young patient with type one diabetes on insulin that already, if you've got a type one diabetic patient or anybody on insulin, we're thinking maybe it's DK reasons that this might set off red flags for DK A specifically, they've not been taking their insulin and both pasted and Iski and, and other people in the EK will try and convince you that this thing here is normal. You should not not take your insulin because you're not eating and your uni but they'll justify it like, oh, I've not taken my insulin for the last couple of days. I'm uncomfortable, I'm not eating anything. So I didn't need my insulin and you're like, oh yeah, that makes sense. But no, it's bad. They should still take their insulin. Um Red flags for the DK specifically is loss of consciousness, abdominal pain and confusion. Um So most common ones that you'll come in, it will be a young, confused patient with tummy pain. Um Big red flags of decay. Ok. Dokey. So we talked about a different diagnosis. Um, in terms of other things, we've got confusion and tummy pain. It could be an oral gastroenteritis, right? There's no reason why it couldn't be, could be dehydrated as a result of it. Um could be thinking down the the thing of maybe like a mesenteric ischemia, ischemic colitis sort of picture like a or an acute abdomen, generally appendicitis, something like that. Um Is it likely not really with the big red flags in the history? Especially? Remember because the acute histories are, they're the one that you think of first, not the, the differentials you think of? Second usually? So what skills DK A? Yeah. Yep. So Cannulas blood glucose, um blood sugars V GS urine dip. Yeah. Brilliant urine dip is one that people do really poorly by the way, like if I was gonna tell you to do the simple skill, make sure you know how to do a urine dip. People do not do urine dip. Well at all. Um main thing, not, not checking the date on it. Uh not waiting the correct amount of time. Uh not putting on gloves. Um Blood sugars as well. Remember blood sugars, you clean with water, alcohol will flag up as glucose. So playing with water always do that wrong or blood sugars always get that wrong. Um Yeah. Um yeah, so stuff for your Cannulas definitely. Um and therefore IV fluids administration certainly. Um because I assume that's what you're thinking there is your treatment of this first and foremost is aggressive fluid recess. Um So yeah, prepping IV fluids, you could basically do anything for this patient. They are, they're gonna be unwell. Um But yes, main things, I'd be thinking blood glucose urine and then down the roots of your, your Cannulas, um your ABG S and then the IV fluids themselves obviously new start very easy one to put in here um for an acute station. Anything else? Um Somebody said sepsis and chap. Um Remember if it's sepsis catheters are on the table. I wish they weren't. But remember CF is the one that they'll give you a chunk. Not the whole thing. So, yeah. Um Cool. OK. Um But if it wasn't on that, if it was an sbar, instead you'd get the news chart again. Check the patient details, date, time straight down here. What have we got in this one here? I'm gonna read out what we've got just in the interest of time. We've got a tachycardia when they're only responding to voice and they've got a slight fever. So we've got 1234 again, turn it over. But if I've just told you that two, I'm worried three, I'm, I'm very concerned. Four is definitely something that I'm very worried about. Um, yeah. Um, by the way, in my mock is, um, you will fail the investigations part of the session. If you do not read out the patient name and details what I would like to like, we're gonna do data interpretation anyway, but I'm gonna tell you just in case you don't come to it. Um, when you get given anything, look at the label, this is the news chart of full name, date of birth, blah, blah, blah. And you say I'll check that this is the correct name and date of birth if it's not a news chart, you're gonna say something else in an ideal world, you give as much detail as you can. This is a chest x ray of full name and date of birth. I would check these details with the patient. OK. So these are four again, use this little thing here if you want to write these yourself to just as a practice. Um but and think for yourself. Now, what would I write? What are my recommendations? So situation is I am wanting to refer to the metro, a 35 year old man presenting with confusion. I'm concerned about a DK A. They're fatigued, abdo pain, increased thirst. Did I make that up? Oh, no, no, but three days it wasn't there now confused past medical histories of type one diabetes on insulin use of five. Did I calculate that wrong? Was it five? Don't tell me, don't tell me I wanna know assessments query D. My recommendation is I need an urgent review. This patient is very unstable. So what do I likely diagnosis? Remember if you've followed the structure that I've introduced here? You've answered this. I think this is DK A due to being off insulin, they've got the increase there abdo pain. It could be just a hypoglycemic episode. Um because that can also present with confusion. They're not eating. This could definitely just be that rather than a full blown DK A. How are we gonna figure out the difference. You're gonna do your ketones, all of that stuff. What my investigations we've already thought about this already cos we're thinking, oh, what skills do I wanna do? But your investigations therefore, I want to do my blood sugar ketones and send off alpha bloods. Can it wait? Do I have to see them? Now? This patient is very unwell. I am worried this patient needs urgent review and management. Is there anything I can do in the meantime? Ok. Right. So that's everything that we're going to do today. I thank you all for stay with me for the entire thing. I appreciate this. A this is a bit of a slog to get through, but we've got a decent chunk of people in. So I hope it was useful to go through. Um If anyone's got any questions now, please do just pop them in the chart. I'm very happy to talk them through. No worries. I appreciate you all coming. I hope these are still useful. We've got a feedback form. Um If you've got any feedback that you wanna put in the chat now, I'm I, we read it. We I will change the presentation if it's just that you hate me, I will get an get make sure that Megan's here for the next one. But yeah, um anything that we can do um very happy to change anything just to make these sessions work a little bit better for you. Like I said about the CBD. If you want people to us to review your CBD, just send it through. I've put my email on the slide at the beginning do that. Um I'm just waffling now if just in case there are any questions, um I will hang around. Um, but I appreciate you all being here. I hope you have a nice rest of your week, next week's session. We're going through specialty staff. Yes, there is a recording for the CBD one. No, that's fine. Um It's up. If you, if you go on to ICU boost as a um a thing, you should be able to see the previous recording and also the slides are up there as well. Um If you complete the, the feedback form, you get a certificate that you can use for portfolio stuff as well. Um If you can. Um And yeah, like I said, um you can also send your CBD ideas and stuff through to me because I appreciate it's difficult to give tailored feedback when you're talking to a, a group of people. Yes. Also if you follow us on Medal, you'll get all the updates and everything will get uh flagged up when we've done it. Any other questions? Brilliant. I'm glad that it's useful for you. I hope the revisions not stressing you out too much. It will be. I appreciate that. We always, it, we seem to have people hanging around like, gosh, I wish someone would ask a really useful question right now and then people don't and they're like, oh wasting my time. I'm one of those people who will hang around but not ask a question. Yeah. So the feedback form should pop up the second that you've um um uh left, but I'll send it through now. Um Brilliant going to hang around. Um Yeah, the feedback link popping up when people have left is kind of annoying. But if you fill it in first and then you leave, it, sends it to you twice and I just, I don't want you to have to go through the trouble of it. Any other questions. And we are slowly dwindling in the number of people. I'm assuming that means not many questions. Thank you, everyone. Ok. I think we're at the point of people who probably have left their computers running and just have me waffling in the background. So I am going to um, stop the recording now. Um If somebody is still here typing a question really aggressively, please press enter even if it is not entirely complete just so I can make sure I see it. Um, but if not, I'm gonna end the recording now. Ok. All right. Bye everyone.