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OK. Can you hear me? Yeah. Is it clear? Ok, amazing. Um So hi guys, I'm Nikita. Um And I'm one of the um Lester Grads. Proud Lester Grads uh currently working in London. Very happy to be here. Thank you for having me. Um So, yeah, we're doing a referral and discussion today. So I think we could just get started basically. Um let me through. OK. So referral and discussion. Um So I, we can start off by talking about the layout of the station, I think to be honest with, with finals, oy, you have so many stations, sometimes it can get quite confusing what the format is. So I think I'll try and um lay it out to you as, as clearly as I can. Um But with the referral and discussion, the the idea is is that as always you'll have the two minute reading time at the start, you go in, you have a look at these documents. Now try and visualize this as I explain it, you're going into the station and you've got these documents in front of you. One of the things we spoke about a lot as, as Fos finals is like the amount of paperwork they give you and it's very easy to get daunted by that. But again, just, you'll have a parking form, you'll have a news chart, you'll have an investigation. So just look through it and we'll go through some tips on how to go about it. But you'll have that two minute reading time for, for those documents. Um, and then the actual station time will start and for the first few minutes, um again, you, you can still look through those documents. You know, you don't have to dive straight into the referral, so you still have time to look through it for 2 to 3 minutes roughly. Um And then in that time, you need to determine the most likely diagnosis as you're reading through those documents. And then for the next few minutes in that station is when you will be ready, you'll, and you'll present that that case to the specialist. Um And they'll be sitting behind this kind of board. Um And you'll sort of pretend that you're on the phone to them and you're having a conversation with them. Um And you decide what request you want to make to the specialist. Um And then there'll be follow up questions from there uh from the doctor across the table. Um And this and they will tell you in the briefing who you need to refer to who the specialist is. Uh And in total that, that time, excluding the, the, the two minute reading time, but the station will last 10 minutes itself. So hopefully that makes sense. You've got reading time, you've got a bit more time in the station to read as well for as long as you need. Um But obviously the idea is you don't take too long because you need adequate time to actually make the referral and have those follow up questions and that's gonna last 10 minutes. Uh Hopefully, that makes sense in terms of the format and you can see how it's gonna work. Um OK, so taking the exam criteria, this is from the briefings, uh the briefing that you've been given, uh but essentially um sort of to go through what they're looking for. Uh So starting off with appropriate referral, um you need to provide relevant information, OK? You're gonna be given a lot of information, but the way you present it in a logical manner, that's, that's the main point and you'll be given lots of things, but you have to simulate that informa uh that information and, and present it. OK? So that's going right from who the patient is to what symptom they came when to what examination bla da da. So, and then after that, it's, it's not just about presenting info, it's about being logical about it. OK? Because we can all information gather about how you're going to logically present it. And again, we'll go through that. Um then you'll have an investigation during the station to interpret, you'll have those documents, one of them will be an investigation of some sort. Um And again, presenting that systematically to the specialist, um, that's one of the things they'll be looking for. And then once you've done all of that, uh by this point, you'll obviously have hopefully a sense of, of the most likely diagnosis and you'll state that when you make that referral. Um And then once you have that diagnosis, you need to also think about the management. So what are you actually looking for? So with this station guy, it's more about it's obviously coming up the diagnosis but also thinking ahead like what actually do I need from the specialist? So what management approach or not even management? Is it further investigations or is it a specialist review? It depends on the scenario in front of you. Um But you need to, you need to think to yourself. Now, what, what do I actually want from the specialist? So that's the management part and then the referral quality is just referring to your reasoning, you know, why are you asking for this review? Like, you know, are you backing it up? Um So that's sort of a breakdown of, of what they're looking for in the station in terms of exam criteria. Um So let's move on to top tips then. Ok. So first thing is take your time, um, it's so easy to kind of like go through these documents and panic, read them, but use the reading time, um, and initial time of your station as well, like a couple of minutes, 2 to 3 hours, you know, minutes and go through all the material and, and just take your time as I said to you, like when we walked into the station, be so daunted with the amount of documents that would be really scary, but work through it systematically. So starting with the presenting complaint, going through the history, the examination, the investigations and paint a story of what's going on with the patients that by the end of it you think, well, I think this is the diagnosis. Um and you know, even if you're not clear, confident, at least come up with one or two differentials, there's something, you know, you know, explain your thoughts but have some sense of what you think is going on. Um Because if you're not 100% confident with it, it will come across in your communication with a specialist. Um So the key is to assimulate the findings, present them concisely. You, you just, you need to have an agenda in your mind as to, you know, what do I need from the specialist? So just take your time to understand the case. Um The second thing is this is not just about this station, any sy station, you have treat it as if you are the F one in real life. And I cannot emphasize this enough. I'm sure, you know, they relate to this working F ones. Once you start practicing, you, you realize actually how much more natural and genuine your communication with specialists is because you've actually got a patient in front of you who you've taken a history from, you've examined, you've looked at their tests, you naturally start developing thoughts on them and you go to the specialist genuinely thinking, well, II need XYZ from you so it can be easy to step into that station thinking you're this nervous fifth year final osk student. But I would highly advise, try switching gears mentally and genuinely think you're the F one treating that patient who needs specialist input. Um So I think that's sort of the key thing that we mentally that that switch that we made in final year was now you're, you're actually this F one. And as I said, it applies to any ay station it, you know, and the stations with Leicester really mimic a lot of real life situations with F one. I think that's what they're trying to, to achieve. So just try and step out of that strict exam environment and just think that you're the F one who's seeking advice um and thinking like an F one. So moving on to the third bullet point, thinking like a F one means you're gonna do your basics, right? So it sounds simple but introducing yourself um providing those patient details um so that they can load it up on the system. So for example, I'd say hi, I'm Nikita and one of the F ones in Ed. Am I speaking with X? Ok. They'll tell you who you're speaking to but play the game. It's, you know, it's all a game. Everyone's acting. I'd like to present patient, you know, X are you happy to take their details down and then you give the hospital number and they'll play the game with you, the specialist. They'll be like, yeah, give me the details, blah, blah, blah. Um This is how it's in real life. Um And I know it's an exam setting but just treat it like real life. Don't just dive in and be like, can I make a referral be professional and slick about it? Um So the next thing is that fine, we're talking about the format of the station we're talking about introduction. Now making the referral itself. How are you gonna do it? You're gonna use SBAR. Uh You, you're probably familiar with SBAR. We use it for handovers. The same thing for a referral. Anytime you're handing over or presenting something to another specialist, just use SBAR because it's the most systematic way of going about it. Um And I've highlighted that both because we're gonna go through it in more detail. Um And then the next part really is, is having a systematic approach to the imaging. So you'll have an image whatever investigation. ECG chest X ray ct MRI one of them. Um and there's some specific mnemonics and formats for each of them that you can use to systematically present them um to the to the specialist. Um and finally, uh be prepared for follow up questions. Um You know, the specialist will, will ask you some things related to the case that are sort of more practical questions. They're not entirely gonna be about just testing your knowledge, they're gonna be practically related to the clinical scenario. And again, even if you're unsure about a diagnosis, kind of relay it professionally and say, well, this is my reasoning. I think this is what's going on, but you know, what do you think? Um So those are sort of the main tips I have for you. I think by the end of all of that, I II think the main thing I want to get across to you guys is is when you're reading, OK, when you're reading in the station, um those documents get a sense of the story have an idea of what you think the diagnosis is, think about what do I actually want from the specialist? What's my motive, what's my agenda? Um And then once you've established that, then it's just a matter of being very systematic with the way you present it. So let's go through actually presenting it to, to the specialist. So sbar is what we said, um you're all familiar with it, but we're gonna go, just go through it quickly. Um So when you start the conversation, as I said, introduce yourself. Say hi, I'm, you know, in the heat on this doctor Needy. Um Is this, who am I speaking with? Can I please uh tell you about a patient? Uh give them the details, they'll be ready, they'll play the game with you and then feel free to, to start um when, when you're reading through the documents at the start, um feel free also II II mean we will clarify this but usually you can write things down um but feel free to also jot down sbar on your sheet so that you have an sbar ready, you know, to kind of refer to at least when you're presenting uh and you know, write down the situation, the background, et cetera and how you want to lay it out. Um instead of just going off from memory entirely, unless you've got a really good sense of the picture when you're reading through um fine. So with situations, so you've introduced yourself in the details and then what happens with this sit, you know, with situation is most doctors usually like it if you state the probable diagnosis at this point to catch their attention. So a lot of doctors talk about how people go on and on and on about SB and then by the end they tell you the diagnosis, but at that point, they've lost interest. Ok, because you've gone on and on and on. I think starting with a probable diagnosis is not only a good way to catch attention, but it's also, um, it's also quite logical in the sense that you're telling them that. Right. I've got this patient. Um, I think this is the diagnosis. Um, and, and then whatever follows on from there is your reasoning why? Ok. So like, for example, I'll give, you know, a situation where you'll say, um I've got a, you know, 60 year old patient who's got, you know, this, this fever or whatever. Um and II think they've got X presentation and then you've got them immediately and they, oh they think this why and then anything you say from that is gonna justify why you think so and you're gonna logically present your findings to justify why you think it's that diagnosis. So that's sort of the first thing for situation. OK? Is, is what you think is happening and you'll say, you know, the patient name their age, the presenting complaint, this is my diagnosis. Fine. So for background um relevant background, OK, where it's not about you just listing off all the possible comorbidities that exist. It's about, it's about saying which comorbidities you think is relevant to the presentation, either as a risk factor or even later on in management. So an example is like, let's say we've got a 65 year old male. Um And, and when you give your situation, some people like to state the background um in that first line if it's relevant, if it's relevant. So you've got a 65 year old male, he's got a background of multiple myeloma and he's presented with a fever. I think he's got neutropenic sepsis. So, it, but it's relevant because of chemo or whatever being, you know, it will at least grab the attention and it'll be relevant. Um If there's any other comorbidities that are relevant, feel free to state them only if you think it's, it's related, but don't just list off every possible condition they have. It's about a logical sequence. Um So that's really for background, you know, anything you think is relevant then moving on to a which is assessment. So again, it's about being systematic. So you have doctors sometimes who will be like, ok, so the bloods were this then the news was this then the x-ray was this go from bedside, basic bedside all the way to your advanced? Ok. For example, if you've done urine dips or cultures and ecgs which are on bedside investigations, don't mention that later on mention it at the start, you know that, ok, fine, let's start off with news. OK? Because that gives you a sense of how stable is this patient at this point. Ok? Because no matter forget the management, if they're not stable, there's no point. So the first point of any, any patient you see is, are they clinically stable? Cos at least then you can put interventions in place to stabilize them. Um But start with the news, then go to your basic bedside stuff like your urine, dips your ecgs, your BMS. You know, the simple stuff. Ok? Because the simple stuff is still important and then you go on to bloods, x-rays, so be systematic about it. And as long as you read it systematically in your reading with the documents, you know, hopefully you'll get a story and you can, it will make life easier for you. So go about it that way because sometimes it can be so much information, you don't know how to present it. So be be systematic about it. Um The final part is recommendation. So this is the key part where you're speaking to the specialist, but like what do you want them to do? Ok. So, II think if I mentioned this before, but I'll repeat it that I've, I've spoken to specialists as an F one and sometimes you get pushed in a certain direction as an F one to go and refer to a specialty and you don't sit down to process, wait, why am I speaking to them again? What exactly am I asking for from them? So I've had conversations with specialists where I'll say to them, this is the case, I'll do an sbar and let's say I get to r and it's not quite clear and they'll, they'll be, they'll be like, well, that's all fine. But what do you want from me? And then I'll think to myself. Ok, I didn't quite think through what is my motive. So I think it's just important to understand that this is the management. This is, this is the next step that I want from them. OK. So that's, that's the main thing about, about recommendation. OK? Is that this is my diagnosis. These are my reasons for it. This is what I feel this patient patient needs next. Would you, would you agree? Ok, just, just be natural about to have a conversation. Um And you know, and uh, what do you think? Is there anything else you'd like me to do? Blah, blah, blah. So, so that's kind of an understanding of, of how you go about an sbar. Um as a uh feel free to keep putting questions, I can see some coming up, we'll have a chance to answer them all the way at the end. Um But we'll just go through this in one go. Hopefully, that makes sense and we're clear on sbar, this is your way to systematically present your, the patient's story to the specialist and grab their attention, justify your reasoning. Um Fine. Ok. So let's move on to actually the imaging itself or not just imaging. Actually, I should say investigations in general. So with investigations, um you can get anything you can get anything. Ok. Um, don't be like oh, they're not gonna give this or it's less likely you're just, just be prepared for anything. Um And have a systematic approach. So there are websites online um that we can always plug in at the end that give a lot of the pneumonics that we probably already use. So probably the most common one that we all know is chest X ray is A to E um but I will let's go through a couple of examples of how you can systematically present imaging. So chest X ray A to start with airway breathing. So cardiac, you'll talk about like the size of the heart, um diaphragm as well, you'll comment on and then everything else is like your, you know, the bones, the spaces, any spaces you'll miss on the x-ray, like costophrenic angles, um lung apcs often get missed. So this is your way to, to present the, the chest X ray. So another example is abdominal X ray. So one of the pneumonics is BBC. So going through the bowel itself, then any surrounding bones and any additional calcification or artifacts that you can see EC G. Again, a very common example that they want you to always systematically interpret it. Because with these investigations, if you're not systematic with the way that you interpret them, you will miss something. And classically whenever you go through these investigations, if you don't bother with one part, it turns out that that's the part that's actually the key finding. So you need to be systematic. So with an ECG, it's always about obviously, with all these images check, you've got the patient first of all, but then with ECG, it's rate rhythm access and any interval. So you start with your rate, you count it, count the number of boxes between the R, you know the R interval, uh the R waves, uh your rhythm is regular, not regular, what's the axis like? And then your pr interval, you know QT interval, just go through each part of the ECG and break it down. And then the other one as example is A, is act head. So blood can be very bad as A, as a mnemonic. So starting with B which is blood uh C cisterns, brain ventricles bone. So these are just some things to, to remember. Just give me one moment. I've got a flu, I'm gonna cough. So I'm gonna mute myself. Do you guys mind giving me just two minutes? Let me just go grab some water. Is that OK? Hi guys. Thanks for joining in. Um In the meantime, whilst we have a short break, if you have any questions, just pop them in the chat and we'll go through them together towards the end of the first half. Thanks. OK, I'm back. I'm so sorry guys, you can probably hear it in my voice. I've got this something's going around anyway. Thank you for your patience. Um Right. So we'll get back to this. So yeah, with imaging, uh just be systematic, there are some common mnemonics. Um there are websites online like ki medics, all of that. So they've got like mnemonics, most of them are taken from there. So use it to present your imaging. OK? Because again, if you're haphazard with your imaging presentation, all of the scores points um fine. So let's move on guys and we are going to have station time. So we've got an example cases always, that's how we learn. Um And basically how there's one or two ways that we can do this. Um Either we can have one of you volunteer, you'll be given mic access. Um We'll give, we'll do this all in real time. So we'll have two minutes of reading time. Uh We'll have a timer running in the background. You'll get to look through some documents. So I think Samir, he's gonna pop a link in the chart that gives you access to all the documents. So there'll be a clocking form, there'll be a news chart. Um And there'll be the relevant image. Um And you can look through those in the two minutes reading time. The one out 38 reading time is over and then the actual station time of 10 minutes will start. Um And if someone volunteers, one of you guys that you want to practice doing it here in this session, uh Then again, we'll set a timer maybe three minutes roughly for you to still continuing to, to continue reading those documents, get us the diagnosis of what you want from the specialist on the other side. Um And then after that, the remainder of those 10 minutes, we'll be making that referral using what we've learned. So sbar um whatever mnemonic for the relevant image. Um and during that time as well, I'll sort of flick back to the main um the main case like the, the briefing that you would get in the two minutes time. So that is something for you to refer to and then you'll have the PDF in front of you with the, with the relevant documents. So that's one way of doing it if no one wants to volunteer, which is absolutely fine. I II would find it quite nerve wracking but, you know, it's a safe space. Um But if you don't want to do that, that's fine. The other way is that me and Nitty do a demonstration where I'll pretend to be the um F one or I don't know if it's best if nit becomes the F one just cos of my coughing bout, but we'll see and then the other person will be the, the, the specialist registrar. Um And we will basically do a demonstration for you of what it should roughly look like. Um So I don't know how we want to do this. We can either just open it up to the floor now and see if anyone, you know, says, can I try? Um, and if we have stunned silence, then I think we just, we just, I'd really encourage you to volunteer. It's a great way to practice this session and don't worry about it. It's your first time. So we'll take it easy. I've put a message in the chart. If you would like to volunteer, do like the message and we'll pick someone at random. Um, so in the meantime, we'll give you some time to download the notes if you have any issues. Downloading. Do let us know. Oh, we've got a like it's an absolutely safe space to feel confident. Go for it. You know, where their learning as f ones, I'm still learning content, you know that I thought, oh, I should have known that for finals. So it's fine. Like it's absolutely fine. Um Don't worry about it. It's a safe space. Ok. So, uh Sim I'll just give you, um, I'll give you my access one time. Ok. You should have, um, my camera access now. Um Can anyone hear this? Yeah, it's a bit muffled though. Yeah, it's a bit muffled. Um How about now? It's a bit better but I'd still say it's muffled. Um, do you have a, do you have earphones? Um, I'm wearing headphones right now. I think, I think headphones don't work as well as like the wired earphones from what I've seen before. So I don't know if you have that to hand. Uh just give me a second. Yeah, no worries. Take your time. Um Can anyone hear me now? Yeah, that's way better. Much better, much better. Sure. Just give me, do I need to at on the video cause I think my internet's a bit shaky today. Uh feel free to but if it starts getting then feel free to turn it off. Uh it'll be all right. Sure. Just give me a second. Uh, yeah. Is that working here? Yeah, perfect. There we go. Oh, hello? Hi. Hey, anyway, yeah, long time. No, see, long time. No, see, hello. Hello. Um, right. Thank you for volunteering. First of all, very brave. Very, very brave. So, um, did you sort of understand how we're gonna go about it? Does it all make sense? Um, yeah, I guess, like, I guess I just have my reading time and then I just try my best and, uh, see how I do first time. Mhm. Exactly. Yeah. So we'll, we'll do the two minute reading time. I'll put the example case up on the, uh, on the screen. And then do you have the PDF ready in front of you? With all the documents? It's, um, I'm just wondering, it's, it's two pages with the ECG and everything, isn't it? Uh, it should have like the larking notes and the news chart, the investigations, everything. Oh, yeah, I, yeah, I, it's just loaded up now. Yeah. Perfect. Perfect. Yeah. So as long as you have that ready, that's fine. Um So whenever you're ready, you've got the timer going, I think you'll start it, start it. Yeah. Whenever you're ready, just shout, I'll start the timer. OK. So once I flip the slide and then once the, when that ends, um So in the actual station again, you'll have, I think three minutes we give for the time to, for you to still continue reading through those documents. So if, if I have eight minutes overall, so it's like I have three minutes on top of the reading time and now five minutes to present it all basically. Exactly. Exactly. Yeah, I mean, it depends on the station entirely, but we're just gonna do it for, obviously for this, you know, situation. So, yeah, hopefully that makes sense. Um, so I'm gonna flip to the next slide, which is the briefing and then I think we'll start the timer. All right. And, and everybody else is, um, you know, go, go through the, you know, read the, don't just mimic it. Uh, uh, the way we are here and then, yeah, we'll carry on. All right. Cool. Gonna flick now. All good Nydia. Yeah. All good. Right. Clicking now. Now time is on. So that is the end of the two minutes, but you can still have three more minutes to read. Ok. S sure. Sure. Um, MZ I can stop right now. Yeah. Absolutely. That's fine. Ok. All right. Sure. So uh good evening. My name is Y I'm one of the f one doctors calling from the emergency department in the uh this evening. Um I'm calling because I'm quite concerned about a 60 year old male that I have which uh suspected extradural hemorrhage. So today with doctor Davidson on the ward run in the emergency department, I've seen uh Mr Sam Root Hospital number H 123456 who has presented today with a reduced consciousness. Um, as mentioned earlier, Mr Sam Root is a 60 year old male who has been quite played cricket earlier today and the cricket ball has unfortunately hit the right side of his head. Um, it was reported that er, he had lost consciousness for a few minutes um after the concussion and uh he regained consciousness shortly after, however, he felt nauseous all of a sudden and had two episodes of vomiting right after the match. Um, over the past two hours before we've seen him in the emergency department, he had become increasingly confused with reduced alertness. Um, all of his history has been uh bystander history provided by his wife and no other symptoms have been um reported so far. Mr Sam Root has had a past medical history of uh previous deep vein thrombosis and type two diabetes that's managed ongoing. He has no known drug allergies but is commonly on Metformin glucoside for the type two diabetes and Apixaban as well, for the DVT, uh he's a Nonsmoker Nondrinker and live with his parents as well and has no family history of note. Um, on general examination, we've noted that his peripheries are quite warm and his, compared time was less than two seconds. Um, heart sounds are normal at one plus two plus zero and his chest was clear on a neurology exam. There were several findings we found that uh power was difficult to assess due to a reduced G CS score. He is noted to have a right sided cranial nerve free palsy and uh increased tone on the left side of his body. He has also upgoing left plantar reflexes on the left side as well. With all of us in mind, we've given him a total score of A G CS of nine out of 15 with three points for eyes, three points for voice and three point for movement as well. Um He is currently deteriorating with a new scores of six. Firstly, uh he had a oxygen saturations of 95% and we have so far corrected it with uh 15 L of oxygen and a non reb mask. His respiratory rate is slightly raised at 21. His BP is high at 15 9/78 and his heart rate is at 58 BPM. His temperature is commonly stable at 36.7 um for his blood tests, his hemoglobin is 136 his white cells are 10 and his neutrophils are 5.4. He does have a slightly raised CRP of 39. Otherwise, his platelets are normal. His us are stable at the moment and we are still awaiting uh liver function tests. Um He has a increased cutting, cutting time for promin time at 15 seconds and an increased a PTT of 40 seconds. His blood glucose is currently stable at 5.6 as well. Um Looking, we have also done an EG for him which shows a sinus rhythm with a steady heart rate of 46 BPM. Um And there's no uh extra findings reg regarding the P wave to cure us and T waves as well. We've also ordered a uh CT head, uh non contrast early today as well, which uh shows a L to form hemorrhage at the right hemisphere. The left hemisphere is also normal. There was also uh signs of trauma that uh matches with the history of the cricket ball hitting the right side of his skull on the CTA hit. Um Overall, with all of these in mind, the patient is currently deteriorating and I have the most likely impression that he's having an extra dual hemorrhage. I would currently um appreciate any advice he would give. Um, if this patient needs to go to neurosurgery at the moment or any other investigations that we could do to stabilize the patient or investigate further while we're waiting for a neurosurgery team to arrive. Thank you so much for today. Thank you so much for, for the referral. Um So I've just got a few questions for you. Then you've told me what you're thinking is going on as you think, um, two minutes left? Ok. So the first question I have is that you obviously mentioned, you want neurosurgical intervention. Is there any other tests or management approaches that you think are important, uh you know, uh prior to the surgery? Is there anything else you think you need to order or do for this patient? I think uh because this is a hemorrhage case, uh currently his hemoglobin is stable, but we want to make sure everything is correct for any interventional surgery with neurosurgery. So I think I would want to also request a group and safe and a cross match as well to perform for surgery as he is on Apixaban for D VTI want to get in touch with hematology as well to advise if we need to stop that or if any alternative bridging therapy is needed for before the procedure. And because he is a diabetic on Metformin and uh Glucozide, as I mentioned earlier, although is quite stable, uh we might need to think of having him know by mouth and possibly starting on available rate insulin. So I might have to discuss it with the medical team as well. Sure, fine. Thank you very much. No, that's, that's fine. I definitely agree with group cross match to prep him and, and the blood thinner as well, most likely you would need holding because of the active bleed going on. So that's fine. OK. Um No problem. So the second question I have for you, um is that, are there any, what aspects of this clinical presentation if at all concern you? Um you know, what could you, could you tell me what's worrying about the if if you're worried at all about the case? What features, what features are you worried about? Yes. So um I think the the most likely concern was that uh was in the history first of all, when he was um initially stable and then he deteriorated. So that post ectal phase is most likely with the coincides with the diagnosis of extradural hemorrhage. Um The new exam he's starting to, he has a uh he has a moderate uh G CS score which is rapidly deteriorating alongside his new score as well. And he's starting to show uh upper motor neuron symptoms of the upgoing plantar reflexes and the hypertonia on the left side of his body. So I'm quite concerned that the hemorrhage is progressing at this minute and interfering with his uh higher cognitive motor functions and uh sensory functions as well. Mm mhm Fine. And that is 10 minutes, but I'm happy for you to carry on finish this last question. Um Yeah. So uh with those neurological changes, you said that high cognitive function is an issue going on. What do you think? What do you think the patient is developing, what's happening? Um The patient is uh developing uh symptoms coinciding with uh raised ICP. Mhm. Ok. And that's something we need to concern about. Yeah. Sure. Yeah. No, that's absolutely fine. And specifically you told me about the CT head and what you can see, um what aspects of it do you think would make you consider this is more urgent? Uh Is there any changes in the CT you think would make this more of an urgent, would require more urgent intervention? Um I from II think the uh the dia the quite large diameter of the lentiform hemorrhage is quite a concern overall and is also causing a midline shift in the CT head. OK. Do you? OK. That's fine. So midline shift you're saying is yeah, for a year. OK, fine. Uh Anything else you want to add to that? Um I'm not really sure I can add on to that. Yeah, sorry, no problem. Um And I guess my final question to you is uh how would you actually monitor this patient in the in for the time being? What, what basic measures do you think you'd used to monitor how this patient is doing clinically? Um I think at, at the current moment while we are waiting for um intervention to arrive, I think we will continue monitoring his uh be observations as well monitoring his blood glucose and his ECG as well. So he doesn't deteriorate any further. Um And I guess if we need more urgent bloods, we will do a VBG regularly as well to keep, make sure his U and his uh full blood count results are all stable until the um neurosurgery team arrives. Fine. Absolutely. That's, that's all my questions. So, thank you very much. I'll, I'm happy to accept the referral for neurosurgical intervention. Um Thank you so much. Thank you so much. Lovely. Ok. Oh my God. Well done. Well done. You need to give yourself a huge pat on the back. That was, that was really, really good. Um You know, how did you feel, uh when you were doing it? Giving your thoughts? Yeah. Round of applause. Oh God. Yeah, that was, you weren't joking when, uh there was a lot of data to process. Um I think ii think it was, it was quite overwhelming. So I did at times had to like stop and think and reorganize everything just so I can present in a bit more succinct manner and not waffle, but it's not as bad as I thought it was. I would say, ok, I'm glad I'm glad it's not sort of, you know, it is overwhelming. You're right. It's a lot to process. Um, but no, I think, I think you were, I think you were clear with your diagnosis. Uh You know, you gave your reasoning um you stated it right at the start. Um There were lots of plus points to be honest, I think you were pretty thorough with the way you presented the findings as well. Um And even sort of you stated at the end, what you want, you need neurosurgical intervention. You, you know, you said it. So you had the diagnosis, you had the motive, you presented what you, what you thought you needed to present. So overall, I think that was, it was brilliant. It's actually, it's fantastic that you're at that stage. I think you should be really, really happy. Um We will go through sort of the example of how the sbar would be and, and things like that. Um I guess in terms of sort of general feedback, honestly, I think you're fine with the, the diagnosis and the agenda, the motive part. I think it's more just making your presentation more slick, you know, instead of sort of using lots of words, using one or two words to describe things. Um and even just maybe honing down on the positive findings um as opposed to maybe stating everything that's going on. So it's more about presenting the key logical findings that are relevant to the presentation. Um Again, it's very subjective but like things like BMS and blah, blah, blah, I mean, he is diabetic so fine, it's important, but I think it's clear there's some sort of trauma. So a normal BM, you know, is not, you know, that's an example. I think it's more about presenting the neuro observations um and you know, the investigation findings and stuff like that. So, yeah, I think it's about just making it more slick. That's pretty much. So, would you, so would you say like the thing I should improve on is like, I should just like, because this is a neuro pathology, I should prioritize more detail on the neuro stuff. And then the others, I can kind of skim through a little bit or yeah, because if you sort of say every observation that exists, you know, sort of, if we start, let's say with. So you said, OK, I've got this patient here. I think this is what going on. Um And then let's, let's take it from the top, right? OK. We'll, we'll go through what you just did. So right at the start, you said hi, I'm XYZ just going, you know, going off the real experience, just say, who am I speaking with. So at no point, did you ask me who I am? You didn't say like, am I speaking with a neurosurgical? OK. So if you ask me, then I would say hi, I'm Nikita and one of the neurosurgical registrars. So just small things like that, we're going from top to bottom. Um And then after that, it's about saying, you know, I've got this patient. Are you happy to take their details down? Just, it's just small things. We, I know it's an exam but just stuff like that. So once we're into it, then you started nicely with your statement that I've got X 60 whatever year old gentleman he's coming with this, this is the diagnosis that I think is going on. Um, and then you started it, I'll tell you why. Uh, when it comes to the background, you told me about the relevance sort of history about the diabetes and also the DVTs, the blood thinner is important. You correctly noted that, you know, the blood thinner, if he's actively bleeding would need to be held. Um So again, that's relevant, right? So then I know someone's come with trauma, they're on a blood thinner. OK. Right. That's, that's in my head. So then moving on to sort of the, um you told me about the story, which was absolutely fine. You told me about the background going on to assessment, you started nicely, you went systematically, you went from basic bedside, the news and you went through each thing until the more advanced of the investigation. So perfect there. Um And then with the news as well. So I think with the news, you can just say I can't remember the exact observations if I go back. But you know, just saying things like they're bradycardic, right? Instead of saying that heart rate is slow, say they're bradycardic at this, this, this, they're hypertensive at this, this, this uh their stats are normal. He's on a 50 m non rebreathe mask, just stuff like that making it more slick. Um with, with the observations like this is what he's scoring for. This is why he's a news of six. Um So just making that slick as you say it and then you spoke about the bloods. Um I mean, even for time purposes, if you think you're running out, you can just say that with bloods, there's no significant derangement that's fine. You know, he had a full blood count LFT using these, I can't see a significant de and his clotting profile is normal or whatever. Um So just being slick about it and making it concise because if you keep reading out each result and number, it can get a little taxing for the person listening on the other, on the other end. But so that's sort of about blood. And then we had the ECG um the ECG you mentioned that it was what did you say about the ECG again? Um I can't remember. I think, I think, I think I said it was like, I think it was uh I'm trying to remember back uh sinus something he said, I think, I think would I say sinus rhythm or I think so. Yeah, I forgot. But yeah, I know we spoke about the Pneumonics with ECG like rate rhythm, blah, blah, blah. But if it looks sinus rhythm, say sinus rhythm or Tachy or Brady or whatever you told me, it's Brady, I think you said, um, at this rate, uh, but you didn't find any other. So that was fine when it comes to the CT head. Again, I think it's just a matter of being more slick with, with the CT head in terms of giving a one liner or two liner of the positive finding that you see on the CT head. Um And again, we'll go through an example as to how you know how to go about it. But I think generally, you know, that was good, so fine. Um I think start to finish. You were really, really good, so well done for volunteering. Um We're gonna share some exam like the examples now. Um So that you guys get an idea. So we're gonna start with. Uh Thank you very much, Tim again, thank you for having a go. Ok. So we've got the sbar here. Um So we'll go through it sort of uh you know, quickly. So I would say hi, I'm Nikki. I'm an F one need. Am I speaking with the neurosurgery register? You'll be told who you're speaking with in the, in the briefing. I have a patient, I'd like to present. Are you happy to take the details out? Just mimic the real life thing. They'll like it. Um And then your first line is I've got a 60 year old male mister root. He's coming with this injury. Um And he's got decreasing consciousness as your presenting complaint, I suspect he has an extradural hemorrhage, hematoma. So that's your first line. You've got their attention. Ok? He's been brought in. You give the situation, you paint the story. Not too long. Paint the story. He was hit on the head, he collapsed, came back and he has been less alert over time. This is his background. He's got a, he's had a DVT and he's got type two diabetes fine. And again, if it's relevant, but don't list out tons of comorbidities. If it's not relevant, then assessment wise, this is his news. This is what he's scoring for. He's Tachy Nick. So using quick words, tachypneic, um his SATS are normal but he's on a 15 L non rebreed mass. He's hypertensive at this. He's bradycardic at this. Um And he's his gcs. Is this this this um And then your examination findings again, positive findings, cardiorespiratory exam was normal. Simple. You don't need to go into like chest. Was this heart? Was this like cardiorespiratory exam was normal? Uh positive findings are he had a right dilated pupil. Um and neurologically as well, increased tone like hypertonicity and upgoing plantar reflexes, bloods were grossly normal. It's just if everything's normal, you don't need to break it down. Um A CT was also requested. This might answer one of the questions in the chat. But if you, when you say I've got a CT again, would you, are you ready for me to present this. So just slow it down, break it down for the specialist. Um and then we come to that. So ct head summary, this is the example, right? So when you're presenting imaging, I forgot to mention this but always say this is a CT head of this patient taking at this, taken at this time on this date because that's showing you're looking, you, you've got the right patient. OK. These are all just things to show off to the specialist. So again, use your your mnemonic for CT head, for example, blood can be very bad and start with again, I can see a hyperdense concho focus in the right temporal region of his brain. His systems are normal, there is some s effacement. Again, this is all to do with breaking down a CT head. Um in terms of the ventricles, there's a ventricular in face, you can't see it in the CT head um but no midline shift. So I think you mentioned midline shift, but there isn't significant midline shift in this case. And then the bones. So you can, there's a skull fracture in the right temporal bone, minimal displacement. So you can then give a punchy line saying I believe they have a right sided dereal hematoma with a temporal non displaced bone fracture and ventricular basement. But there isn't any midline shift. It's a lot and I it's a lot of information but just try and take the positive findings and spell it out in one sentence to them if you can. Um And that will be, that will be slick. Um in that sense. So that's the example of the CT head. Uh Sorry if I'm going too quickly, but this is just to give you a sense of be, be slick with it, keep it short, keep it punchy, ok? Um Don't break down everything if you, if you don't need to, if everything's normal and the one thing is positive, talk about the positive thing and then just say everything else was grossly normal. Um So you've presented an investigation, but don't forget you've still got some of your sbar left. You need to make a recommendation. So you're like you nicely said, uh Sim, I believe it requires neurosurgical intervention. Um Would you agree? Is there anything else you'd like me to do? That's it and, and have those statements already in your mind and then, and then it, it sh you should have a complete complete sbar. Um That's how the station will be. I think s sim nicely highlighted. It's, it's a lot of information that you have to gather. But as I said, paint a story and try and add up key positive findings that make you think this is why I think it's this diagnosis as long as you highlight those things in your mind, like when you're looking at that news? Ok. He's a six. Ok. He's moderately unwell. You know, neurologically, it seems like there's some form of ischemia or stroke picture developing as a complication of the, of the bleed. He's clearly developing these upper motor neuron signs, like you said, um, the CT head clearly shows me that there is that bleed. Um But you know, there's no midline shift, it's not absolutely terrible. Um The other thing that was hidden in this case is the, is the Cushing's reflex. If you remember with extradural bleeds, they tend to have a, they have a high BP as a, as a way to maintains sort of that BP. Um And but the heart rate actually, instead of it slows down. So that's why he was bradycardic and then he was tachypneic which fulfills the irregular respiration. So Cushing's as a triad. If you're not aware, you can't remember, you can go over it, but that was just a hidden thing in the case and it's usually a, a sort of serious sign or it's getting quite bad. Um The, the presentation. So that was just a hidden ger in terms of what makes you worried about this presentation. Um So I hope that was clear for you guys. You've got an idea. Um If I can summarize for this station just to wrap things up, I think the key thing is like, sim nicely demonstrated, paint the story, understand the diagnosis, determine what you want from the specialist. It doesn't have to be a procedure. It can be anything fa further review whatever um and present that with short punchy statements, with your key positive findings that make you lean towards that diagnosis. Don't list everything you've got in front of you. Tell them the stuff that makes you think why you and, and they'll see it, they'll hear it. They'll be like, OK, this is why she's thinking this because she's told me these are the positive findings. Um and then, yeah, be systematic with your, with whatever imaging or investigation you get. Um I think that's, that's all I all I have. Um n let me know if I've missed anything in terms of the actual case. Um But that's what I've got for referral and discussion. No, I think that's uh that's great. Thank you very much, very much. Yeah, that was really good. Thank you. We'll just take some questions if people have any. Um And I think just in the interest of time we're approaching 8 p.m. So if Nikita, you can answer the questions in the chat box and everybody, if you could follow the answers through that, um we'll move on to the second part. So going from the top, uh what's the first question? Let's see. Uh How long do you get to read the documents? And how long do you get to do the actual sbar? Yes. So just to clarify two minutes reading time as always. Um And then when it comes to the station, it's up, it's, it's up to you. Uh, how long you need. Um, so like with this case, we did say three minutes, but that's not how it's actually gonna be with us. So you have three minutes in the station. Um, it's essentially be, they'll, they'll tell you the case, maybe that, that we've got this, um, when you're happy to make the referral, have a read through. Um, and then you take your time, um, spend roughly in your mind GD, you know, 2 to 3 minutes, but try not to spend too long because you need time for the referral. You need time for the discussion. So there's no fixed number, but I think we'd always recommend 2 to 3 minutes roughly. Um, and hopefully in the first two minutes, the reading you would have guessed, got a sense anyway. Um, and the actual s is the time remaining. So if you spent 2 to 3 minutes like we did here, um, and, and it was nice that Sim suggested that I'm actually happy to start, you know, uh, we didn't need to prompt him that the time is over. So it's up to you essentially, um, however long you need, but just be conscious, you don't spend too long. Um, fine. Next question. Next question. Next question. Will we need to systematically an investigation during? Ah, yes. Ok. So that was the other thing. So when you've presented your, when you've got to a in sbar and you're gonna present your investigations, I'd say at this point, um, you know, pause and be like, well, ok, I've got this ct head in front of me. Would you like me to present it to you? Um, and then at that point, the special bit. Yeah, go ahead. So, just try and break it down a bit. Don't continuously keep talking. Just say, OK, I've got this image in front of me and it's a moment of pause to take a break and, and actually present it systematically. Hopefully that answers that question. Um I can, I can I quickly just um can I quickly just interrupt just for just for the sake of time, could you reply to the questions with text responses in the chat? No problem. And we can start with the next one. Yeah, thank you. Thank you so much guys. I'll ask the questions. Cheers. We'll go on to the next, next, we'll go on to the next, the next station. OK? Thank you guys. So any questions you still have about the first case, do keep putting them down in the chat. Nikita will be answering them in the background. And uh thank you for being a great audience. We'll move on to the second part of our session which is prescribing safely. And yes, just to know there will be more cases that will be released later on in the year as we progress through the course. So do keep an eye out and um, we'll move on. So this is prescribing safely and just as a general layout of how the exam functions, you will have a 10 minute station which is broken into two halves in the first half. You have five minutes to analyze the charts and notes that are available in front of you when it comes to prescribing, and you'll be asked to suggest appropriate reasoned investigations to the examiner. So you can't just say, can I request a full blood count for this patient? They will want you to expand further, what are you looking for? And this is why you need to know what is included as part of the test panel and what you are requesting it for. And then in the next five minutes, you will be asked to interpret the results of the investigations you have requested and then also diagnose the patient. So you can mention your differentials to the examiner. Um say I'm most concerned about this diagnosis, but I would also want to rule out these other things I'm thinking of and specify and say the most likely diagnosis you're working with and then use that knowledge and the information to then prescribe as per the results that are available in front of you. Then just in terms of the layout further, it can either be a paper chart or e prescribing for your year. And if you are a Lester student, it will be on nerve center the university will communicate with you further, whether it's going to be the drug charts were normally used to in the 3rd, 4th and 5th year or if it's going to be a nerve center, which is a little bit different. Um and it can be an adult or a child patient. And in the station, you will have access to the BNF, a calculator and local guidelines will be available if required. And when we do mention local guidelines, it is a clue to saying a lot of antibiotic prescriptions can come up for this station. So um these are the examiner's expectations. Um This will be sent out to all of the lesser students. So you can have a look at this in your own time. Um But generally it goes through what they're looking for in your prescription and also your approach to the patient and how well you present it and how legible your prescription is as well. So when it comes to assessing the patient, what are we looking for? So you will be given a case where it says you are the fy one on this ward or this part of the hospital. And your patient has presented with X symptom a lot of the times it's going to be very vague. Um They've presented with pain in a specific region of their body or they have come in with a fever or a cough, which can give you more of fluent saying it's likely an infection which is going on in the background and requires you to prescribe an antibiotic. Um Then you will be asked to review the notes and the obs chart, then prescribe using the available information in the station. So the first section is information gathering. We need to out of all of the documents available in front of you. Look at uh the information to summarize for yourself. Do you understand what the history of presenting complaint is? Do you have the past medical history information in front of you? What medications do they normally take? What allergies they have? And also just clarify whether it's a rash or an upset tummy or if it's something more severe like anaphylaxis, it should normally be written down there, but you will have the space to ask the examiner this question and they may or may not choose to provide you with the information depending on how they feel the um, information is going to modify the station, whether it is relevant or not. Um, social history can be really helpful because a lot of the medications can interact with alcohol and this is bringing you back to your cyp enzyme inhibitors and inducers. So just have it in the back of your mind to ask about alcohol, smoking and work history as well. Um, and any chance of pregnancy, a lot of the medications do affect pregnant patients or breastfeeding patients differently. So just make sure you are keeping that in your mind as well when looking at the case and then when it comes to examination, um you will be either provided the information or the examiner will ask you about this as part of um asking you what further investigations would you like to do? Um Generally you want to gather information about the systemic examination and this helps to identify the differentiating features. Um So for example, if someone's coming with abdominal pain, um keep an eye out to see whether they are peritonitic or not, because if they are, this is going to be something that's going to be managed very urgently with um the higher dose of antibiotics or the IV route of antibiotics. For example, then summarize your findings to the examiner with reasoning within the first five minutes. So you need to mention what your findings in the case are, what your differentials are the likely diagnosis. And then also suggest your appropriate further tests you'd like to include with reasoning as well. And as we always say, we want to break down the investigations into three categories. So the first one is bedside investigations, bloods and then also imaging. So in terms of bedside, these are some examples, you could be asked to go through um what urine tests you would like. So is it a culture you're asking for or is it just a dip or is it a pregnancy test? So these things you can specify in the station um if you're asking for cultures, what kind of cultures are you asking for? Um a surgical site, infection culture? Is it a wound swab? Um Is it a culture of sputum? All of these things? You will have to specify and ask what you're looking for? Is it microscopy culture and sensitivity or is it something more specialist you're looking for? Then again, you can request an ECG VBG and ABG SI normally class them as beside investigations because you physically have to go run them in real life. So once you have done this, moving on to the bloods, um these are some of the tests you can ask for a full blood count, which includes your um hemoglobin and cell count indicates any infection or anemia in the background. Use these for your renal function as well as your electrolytes. Then with your liver function tests very important to ask this, ask for this. Um because a lot of the patients can have hepatic impairment, which again affects how the drug is metabolized in the body. Then moving on to bone profile, you're looking out for calcium and phosphate. Um CRP again indicates whether the patient is in an active inflammatory state and further supports your diagnosis of an infection. When you are responding to the examiner questions of the likely diagnosis, then you can ask for a glucose as well. You can ask for TFTs thyroid function tests, um coagulation depending on the kind of case you may decide to ask for coagulation and also blood cultures to check for sepsis. Then when it comes to imaging, these are some examples of what you could be presented with. You could have a chest X ray, you could have an ultrasound scan of any region of the body. Um And you have to specify what you're looking for with that. If you're suspecting, it could be something like acute cholecystitis or um simple gallstones, you can ask for an ultrasound of the abdomen, then moving on to Doppler scans more, looking out for your DVTs through this and then a CT head is something you can ask for as well. Ok. So the other thing to mention with the station as well is if you miss out an investigation, the examiner will still provide you the necessary information. They won't withhold the test from you just because you haven't verbalized it. Um It, it may affect your score because you haven't been very um thorough in your requesting of the investigations, but they will still give you the information to allow you to safely prescribe for the patient later on. So you will still be able to do well in the station then moving on to our approach with the patient. Um So this is something I've taken off from the PSA um book and a good mnemonic to remember is prescriber and this applies to any kind of prescription you do in real life. A lot of these things don't apply for this station specifically, but this is a good example to have in front of you. So whenever you stop prescribing, you need to first check the patient's details. Um, note it down on the drug chart as well and then check for allergies. What kind of reaction do they have then with the s your signatures, don't forget to note down your signatures in the drug chart. These are all easy marks to have in the bag before you actually start to think about what drug are you prescribing and how you're going to prescribe it on the chart. So get all of this done out of the way first, then moving on to the route, whatever you're prescribing. What route are you going to use? Is it going to be oral IV or um like AAA rectal root or is it gonna be transdermal? And then also check on the BNF. Is that route available? For example, with Doxycycline, which is an antibiotic, you don't have an IV root for Doxycycline. It's always going to be oral. So these things you can check on the BNF um in the station, then with IV Fluids more for real life, not going to be something you will be asked to CP, prescribe in the station. But that's not to say you won't be asked to just prescribe fluids. For example, you could have a patient who is hyperglycemic and you're being asked to prescribe dextrose for them. Um 10 to 50% glucose then um blood clots. So in real life, we want to always prescribe BT prophylaxis or treatment for our patients in this station in your AY, it's more likely you could have a DVT or a PE. So you could be asked to prescribe a treatment dose of the appropriate blood thinning medication. Um, antiemetics. Again, in real life, we tend to think about co prescribing this with medications like morphine in this station. This could be one of the medications you are asked to prescribe for a specific cause behind someone's vomiting. Um and again, with relief of pain, you do want to think about your who pain ladders start with something that's more low dose and less um carries less side effects and then move on to your stronger painkillers and be very careful about the dosing and always keep in mind renal impairment or hepatic impairment for your patients. As we've been saying, the other thing to keep in mind is the patient will already be on some medications. So always just glance over them, screen for any drug drug interactions and then in their blood results as well. Check for any electrolyte imbalance. Do they have a high sodium or a high potassium? Um or is something wrong with the calcium? This will give you a bit of an indication into the condition as well as how to prescribe safely for your patient. Then again, pregnancy and breastfeeding as we said, um and just for a more holistic assessment, are there any special requirements for the medication? Does it, does it need to be given at a specific time of day? Or there, are there any dosing instructions you need to write down on the drug chart when you do prescribe your medication? Then moving on to some of my top tips. So, um with the station, it is a chance for examiners to evaluate your clinical reasoning, your diagnostic skills and assessment of contraindications and cautions whilst you're prescribing. So it's a very real life based assessment. And then you're going to be asked to record patient details, allergies on the chart before prescribing your drug choice because this means a lot of the easy marks are in your bag and then you will get better with gestation as you progress through the year because you'll be starting to practice for your PSA exam. And this directly helps with gestation. Um In this case at Leicester, your examination is most likely to have someone with a renal impairment. Um and that's going to affect the kind of dose or the frequency at which you give the medication. And then also do know your scoring systems, something like curb 65. You will be asked to remember this um off by heart, but something that's a little bit more complex like cure risk or well score, you're not gonna be asked to remember it. You might have some guidance in front of you to help you evaluate whether this patient does need a treatment or not for that cause. But just be aware, these are the kinds of scoring systems they can have and the kind of medications you could be asked to prescribe in relation to them. So whether it's antibiotics or blood thinners or any cardiovascular modifying medications. So, um with the next half of this station, we can practice. So what we'll do is we'll go through the first half together and then the second half half, I'll let you guys all go off and practice on a sample drug chart as well. So you are the surgical fy one in the ed at somewhere Royal infirmary. And John Brown is a 56 year old gentleman who's presented with acute pain in his right knee, you'll be asked to review the notes and abs chart then prescribe using the available information in front of you. So, uh so if you can release the document with the first case notes, please in the doc in the chart, then everybody can follow through with me. So in the clocking notes, you know that the patient has had a three day history of acute right knee pain and the severity is eight out of 10, the patient is able to weight bear, but there is pain on movement, there is no trauma and X ray of the right knee does not reveal any abnormality in terms of examination, the patient's knee is warm and erythematous. There is full range of motion. However, there is marked swelling compared to the left knee. Past medical history is significant for hypertension, diabetes, obesity, ischemic heart disease and asthma. But there is nothing else of note drug history. He just take some over the counter paracetamol. Um has salbutamol inhaler, ramipril gliclazide atorvastatin on his regular prescription and he does not have any allergies in terms of his social history. He drinks 15 units of alcohol a week and he smokes 10 cigarettes per day. And you've also been provided with a news chart in front of you, um which shows that, you know, he's very hemodynamically stable. He's been a Peroxyl for his first assessment and he's not on oxygen. So his new score is zero. So what are our differentials? Do you guys just want to pop something in the chart that you're thinking could be the reason why he's presented this way. Septic arthritis. DVT. Good thoughts. Yeah, more septic arthritis. So that is something that is a very severe diagnosis. We do need to rule out um, a lot of red flag features. You'd want to keep an eye out for cellulitis. Ok. Gout. OK. So he's come in with an acutely swollen monoarticular joint. So this patient has not had a trauma transient. Synovitis is a good thought, osteoarthritis. Yup. I'm hearing some really good suggestions here and all of these things you can mention as part of your differential at this stage to the examiner hemarthrosis as well. Hematoma. Yeah. So definitely osteoarthritis given his age group is very likely. Um, gout is another thing we'd want to rule out. His x-ray has been normal. No abnormality, no fracture was noted on there, but he's still got an acutely swollen joint. Pseudogout is something that goes along with gout. We won't know this unless we do further testing, whether it's gout or pseudogout. And as everyone has been saying as well, we want to check for septic arthritis and rule it out. So, moving on from here, um, some of the investigations we've done. Um, so bedside blood and imaging, do you guys want to put down some bedside investigations you'd want to do for this patient in the chart again, please. Observation. So we have got observations on the news chart. Yeah, new score was zero, joint aspiration again, a gold standard test. This will tell us exactly what's going on and what are we doing? The joint aspiration for ECG as well? Yeah, that will be done as part of the workup microscopy and culture and there's one more, one more thing I'm looking for. Yeah, bloods will come to urine dip. Yeah, sure. We can do a urine dip as well. That's all right. Don't worry. Yeah. So, um, joint aspiration is a key investigation we want to do alongside urine dep ECG which will be done as part of his workup. While he's presented in the ED, we need to look out for crystals. Now, this is very important because this helps us to directly identify whether it's gout or pseudogout. OK. So moving on to the bloods. So someone's already mentioned CRP white blood cells, um any other bloods you guys are thinking we should add on E sr so you can ask for an ESR, it just depends on which trust you're in. Some trusts prefer to do a CRP first and don't actually do ESR S but this is something you may want to do later down the line. Yeah, exactly. So we'd want to do a full set of routine bloods for this patient, looking out for different things. So you'll want to ask for a full blood count, urine electrolytes to check for renal function as well. LFT S as we said earlier for hepatic function, two bone profile C RP glucose, we can do um he's a diabetic patient. So we can just add it on to our investigations. However, however, we're not thinking it's a diabetic related presentation this time. Uric acid is something you will want to request as well. If you're thinking a go bone profile is for calcium, yes, then when it comes to imaging in your packs, you will have been given an X ray as well. So this is just for reference here from radio pia. This is the right knee, no fracture to be seen, no osteophytes. So we can pretty much safely rule out osteoarthritis at this stage here. And again, if you miss out any of these investigations, examiner will provide it to you. So I hope nobody has looked at it at this just yet. But do you want to put down what your most likely differentials are from what we've looked at so far? So this is what you find. Uh, so maybe if you can share the second document as well. So when you do the joint aspirate, you find that there is a small volume, clear straw colored aspirate, it does not have any white cells, no red cells. And on microscopy culture and sensitivity, there was no growth and in plain polarized light. So this is when you do the test for crystals, you see that there are negatively birefringent needle shaped crystals. Um When you do the bloods, you find that on full blood count, hemoglobin is 100 and 30 white cells. 5.6 new is 3.7. In the real exam, you will have the reference ranges given to you. But all of these are normal. On FBC E again, everything is normal, normal. Um sodium is 138 potassium is 3.9 urea 6.8. That's also within normal limits. Creatinine is a little bit high. 145. We're looking at something below 100 and 20 his EGFR is 48 bone profile. Nothing wrong with the bone profile. No, raise calcium FT S again, all is normal. No raise, transaminases, CRP is 35. So a little bit raised. Um, but we're not completely unhappy with that. HBA1C is 48. So we know he's a diabetic and that's actually pretty good control for a diabetic uric acid. We see it's 5.4 and it's within the normal range. So out of the four differentials we were talking about earlier, we thought it could be osteoarthritis, gout, pseudogout or septic arthritis. Given these examination findings, what do you guys think is a likely diagnosis? Ok. We have a shout for gout in the chat that because of the negatively bent needles and high alcohol consumption. Yeah. Yeah. And essentially what we've done with these findings as well is we have managed to rule out the others with the normal X ray and the blood results tell us he is not infectious at the moment. His white cell count is normal. Um And there was no growth on the aspirate. So, septic arthritis is something we have ruled out. So essentially our most likely diagnosis is gout and this will tell the examiner. So let's move on to the second part of the session where we go through prescribing and I'm going to put on a timer for five minutes in the document that's just been sent through on the chart. There is a link to AU L drug chart. Um If you want to take the next five minutes to go through the BNF, use a calculator and using the available information prescribed for this patient, an appropriate drug in the right location of the drug chart. We'll come back at 28 past eight. Um, and then we'll go through the answer from there. Well, someone's just asked how many drugs are we allowed to prescribe? You can prescribe as many things in the chart as you want, but they're only looking for one appropriate prescription. OK. So that brings us to the end of the first five minutes. Uh sorry, second five minutes of the station. Um I hope everybody's had a chance to prescribe a drug on their charts. If not, I hope you had a look at the BNF and tried to think of a drug you would prescribe in this situation. So let's prescribe together. I will just show you how I approach the station and everybody may have a different way of going about this. But I tend to use a approach where I refine, what exactly am I choosing? What am I prescribing? So I always first start off with filling out the patient details. It's always the easiest step. Get it out of the way. So you're not forgetting anything then, right? So then for any other prescription I'm doing, I will want to think what medications are used for this condition. I'm thinking is the most likely diagnosis and I often think of it in terms of categories? Like, am I going to prescribe um a beta blocker? Am I gonna prescribe an ace inhibitor? That kind of a thing. Then after that I think about does the patient have any allergies? Because if they do instantly it rules out that category or that specific medication, then I move on to contraindications. Does the patient have any other medications? Which means I can't prescribe it or do they have a poor renal function? Which means I can't prescribe it. Um So these are the things I used to refine my prescription. And then now with this case, specifically, when it comes to gout, we want to prescribe either nsaids or colchicine as a first line medication. And either of these can be used, there is no um nothing stopping you from choosing one over the other at this stage. Then we're thinking about the patient's drug allergies and we know they don't have any allergies so we can proceed from here. But when it comes to contraindications, this patient has quite a lot of different things which would point you away from using nsaids because you firstly want to avoid using NSAID S and ace inhibitors together. Um And this is something that comes up a lot in your psa. So you'll become very, very quick at recognizing this when, when this kind of drug drug interaction is about to happen, this patient was on Ramipril for their hypertension and you want to avoid this because it's going to further um impact their renal function and their EGR was already poor with the raised creatinine. So you want to avoid nsaids at all cost. And they also have asthma in their past medical history, which means you again want to avoid nsaids. And this would mean you proceed towards using colchicine. And when you do go on to the BNF, um check up colchicine and then look at the dosing, but also look at the renal function section. And on there, you will find that it says we need to reduce colchicines dose or frequency if the EGFR is between 10 and 50 if we just go back very quickly, this patient's EGFR was reduced, it was 48. So it's within the 10 to 40 range. So when you go on to B and F, yeah. So as I said, again, you filter down from opposite contraindications down to cautions. And then when you go on to the BNF, you will find for acute gout, you are going to be prescribing 500 mcg 2 to 4 times a day. Um And then when you further go on to the renal impairment section, it tells you to either reduce the dose or increase the interval. So you could on your prescription chart, either prescribe 500 mcg of colchicine two times a day or three times a day and you filled out all of this section for patient details and then coming onto the actual drug chart. You'll put down the name of the medication just here, then say that it is for gout, put down the route, which is oral, the start date of the medication. What times you're giving it now, you can give this at any point. You could say it's a lunch time or an evening dose or a morning and an even evening dose. But I always like to space out my medications evenly. Um, whether it's antibiotic or anything else, if they're taking it more than twice a day, space it out evenly. Um, and at the bottom of the usual drug chart as well, it says what times drug rounds happen. So you can just use those to populate the time field and then you want to put your name, your signature and also a bleep number. You can make this up in your exams. I always put 123 and that's the end of your prescription you have prescribed safely keeping in mind the patient's absolute contraindications as well as cautions. And, um, you're hopefully gonna help them with the gout through this and then come back and reassess the patient after. Um, you have seen them in the ed. So any questions about the prescription or gestation in general at all? Yes. So with the nerve center prescription, this hasn't been done before. This is something new for your year. And I think it's just an idea which has been floated about. Um, they will communicate with you whether this will actually go ahead. Um in terms of how do we prepare for it in our own time if we're not in ul um that is a tricky one. but definitely do mention to the medical school um if you don't have any rotations in U HL at all and they will be releasing some sporting resources for you, it might just be a case. You have to raise it up with them. Always mention why you are doing each investigation. Yes, you have to always justify and support your reason for doing the investigation. Should you put an instruction on when to stop the medication? As the BNC is not exceed 6 mg? Yes, you can put it down in the special instructions box as well. What happens if you write the prescription in the antimicrobial section by accident? So, um this is one of the things of this station, you have to be careful what section you're prescribing the medication in. Um There is the antimicrobial section, there is the oxygen prescription sta uh section and then the fluids as well as the regular medications and PRN medications. So you have to be clear what you are prescribing, how often you're prescribing it and go to the appropriate section. Flick through the whole chart, um or a nerve center. They will have a different way where you can select that. This is APR N prescription or not. Is there somewhere we can access this week and last week's slide. Um So last week's resources are all up on me all. Uh The recording is also there as long along with the supporting resources with this week's session, I will just scroll on to the next slide where we have our feedback QR code. If you can all fill this out, give us some feedback. So we know how to improve for the next section and we know what we did. Well, um then all of these resources from this week's section will be released on me all through there. OK? Any last burning questions, we'll hang around for another two or three minutes. But just to let everyone know our next session is going to be on Wednesday 7 to 8:30 p.m. as always. And we'll be going through POSTOP patients and any complications you can have after surgeries to clarify for this case as is reduced. Would you recommend lowering dose or the frequency? Yes. So um on the BNF, it said you can give them 500 mcg 2 to 4 times a day. I went with the two or three time one because this is a lower dose and it's going to support them with the renal function. Caution in terms of reducing the dose. Um I thought one of the easiest way to go about this is reduce the inter uh so increase the interval between each of the dose. And I went with a BD prescription of colchicine as it's the safest. And I'm not dealing with complex calculations of what pills are available and aren't available. Um If you did want to check, you can always go down to the medicinal forms on BNF and check whether there's any tablet which is less than 500 mcg. And you, you could prescribe um that medication dose inside if it is available, feedback form state is not accepting responses right now. Ok. Just bear with us. I'm going to quickly go fix that. Ok. It should be working now. Try again. Ok, great. Oh, the PSA exam is a very big thing and I think it deserves a session in itself to be honest with you. Um, but there's lots of things you can do. Um, online, there's a lot of helpful websites, videos on youtube and also the preparing for the PSA book was very helpful. And I think just going through your general prescri uh principles of prescriptions, like what are the categories of medications? What are the general indications, cautions, contraindications? Um That's help. Uh, that's a really useful place to start and then it helps if you categorize medications and speak to them. Uh, and then actually just, uh, talk about the different medications and learn each individual drugs, contraindication and side effect as well. Yeah, we'll see if we're able to arrange a session on this later on in the year. Thank you for joining guys. Ok, so we'll stick around until um 845. Um if anyone has any questions and then um we'll end the session though. But yeah, thank you everyone for coming. Um Yeah, when you did do the sbar, um you actually did a really good job firstly well done. Um It's a lot of, you know, on the spot thinking when you're presented with so many documents and um it's just a case of being organized really and don't worry about the last part when they examine it does ask you a lot of different questions because you know, they're gonna ask you some questions which are simple and you can answer them. But other questions will be more complex. And honestly, the examiner doesn't expect you to answer them. Um You know exactly what is going on. They want to see how well you respond to them because that's the whole part of referring as well. If you don't know the answer to a question, how do you respond? Do you be honest and tell them this is the best of my understanding and this is what I'm telling you or um you know, you, you say something which they weren't looking for and they then find a way to basically further understand what your level of understanding of the case is. So don't worry about it. You stayed within your capacity and you said this is what I understand from this case. This is what I'm telling you. So you did absolutely fine. Um I think it's just a case of spot recognition when this case was actually presented uh because it's cushing's reflex in the background. So that's, that's completely fine. I think that's what Nikki was trying to ask with the last question.