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Yeah. So today, Vanessa and Bethany will be talking you through managing uncertainty and then multimorbidity and polypharmacy with cases for both. Um As always, please don't use this as uh actual medical advice and we don't take any possibility for the uh factual accuracy of the content. But if you do notice any errors, please let us know at the following email and we will quickly correct anything uh regarding all the, regarding all the cases and uploading the videos, etc, etc. Um I'm just gonna do all of it at once at the very end. Um And then the program will be made open access. So you'll, you'll be able to access it um regardless of whether you watch the sessions or not. So, within the next two weeks, I'm just gonna sit and do the whole thing at once and then everything will be uploaded. This is the team that's been talking you through various sections. If you're joining us for the first time, it's all comprised of for the Lester students and our junior doctors. So they're very well aware of what actually you need to do, do well in the sys. So I'll hand over to Vanessa to take you through the first half of the talk, which she has managing uncertainty. Great, thanks so much. I hope you guys can hear me. OK. So I'll be going through the managing uncertainty station in the SK, which is primarily GP based. If you have any questions, just feel free to put them in the chart and I'll try to answer them as we go or towards the end. OK? So just a couple of details about the layout. So essentially the station um will have a simulated patient. So it will be an actor that you'll be talking to and it's a 10 minute station with five minutes um that you have for history taking and then you get some uh sort of investigation and examination findings from the examiner and then you have five minutes to explain the different rules and the management plan to the patient. Um So any relevant findings that you need um or might potentially need to come up with some differentials and management would be given to you by the examiner. Um But the examiner is sort of throughout the consultation is purely observing. So you um won't need um So you won't have any questions from them at the end of the station, it will just be giving them, giving you the examination findings and then you'll primarily be talking to the simulated patient. So this is the station layout, I've just taken from the assessment briefing slides So essentially, it will be based in general practice and you will be seeing a patient who will be coming in with some sort of symptom. And essentially, we'll go through a couple of cases later. But that when you are revising for this stage, you should try and come up with a list of symptoms that could potentially lead to sort of uncertain diagnoses. So some things that of you probably see and come across in your GP placements, um are sort of symptom based directed investigations and management. So essentially in five minutes, you take a focused history to all these examination findings and then you explain your diagnosis and management to the patient. So I'll go through some sort of important tips for the station. So essentially it is a managing uncertainty station. So the diagnosis definitely, you know, it won't be obvious to you. So it definitely will be uncertain. So it's really important that you have a logical system based approach and we'll go through this in a couple of cases. But if you split your history, taking all your investigations into um the different body systems, so like cardiovascular respiratory gi psych, whichever is applicable to the presenting symptom, it will help you to narrow down and give at least sort of 2 to 3 potential differentials to the patient and try and explain some investigations and management options that you can offer. Um always in any sort of GP setting. Always remember, ice um it definitely will be, so you definitely will get some points on the mark scheme for addressing this and try and address it in your management plan as well. Um And that's one of the things the examiners will be looking for that, have you sort of met the patient's expectations during the consultation? And are you comfortable explaining the uncertainty to them? So in terms of management plans, it's quite this um station is quite time pressured. So it will be difficult to try and you know, recommend all sorts of different things that you would ideally do in a real life setting. But if you start simple and then if you know some more specialist investigations or referrals, you can potentially do them. But just remember you are in a general practice setting. So, um, you know, don't tell the patient, you'll be doing some sort of, you know, scans and CT S and things because it the realistically wouldn't happen in a GP setting. Um Really the main thing that you're assessed on in this station is um the similar sort of things that you do in everyday life as a GP. So, you know, suggesting valid investigations, a safe management plan and in GP land always important to give safety netting advice uh to the patient as well. And we'll go through the cases and it will become more clear but sort of the key symptoms that you'd be advising them to seek urgent medical attention for. So, um, as usual with any sort of consultation, um you'd, it's really important to pick up on the patient cues that they are giving you and they will give you quite a few cues and that will help to adapt your questioning because, you know, it's a focused issue that you'll be taking and the examiners and the simulators are aware that you need to have enough information to be able to formulate some sort of management plan and differential at the end of the five minutes. So try and pick up on the cues. They don't necessarily have to be sort of symptom based or medical. It can be social cues in there for social history, for instance, family history and just have, if you have a biopsychosocial approach in any GP station, it will definitely save you because even if you can't think of the certain medical investigations, you can always offer some sort of um psychological social management options to go with your plan because it's five minutes only to take the history, you would need to ask some closed questions. So normally in a history taking station, you would get 10 minutes, but because this is quite really time pressured, um, it's ok to ask some of the closed questions that you do need to ask, um, especially some of the red flags. So, um I would suggest, you know, if it is relevant to the presenting symptom and we'll go through the cases, but oh, I'll go back a bit. It's always important to screen for these three things I really remembered. So fevers, night sweats, um weight loss, um if you screen for them, um depending on the presentation, um it will help prove to the examiner that you are thinking through some of the more serious diagnoses and also screening for them whilst also offering a safe management plan and safety netting. So just a reminder about the MTG um diagnostic strategy. So as we mentioned, um the most likely was a probable diagnosis um in this station, you would actually, if you are, you know, you'd actually lose marks if you were sort of appearing really confident with one particular diagnosis that you definitely think it is because the station has been designed to be uncertain and it's assessing your ability to be comfortable with the uncertainty and explain that to the patient in a way that's understandable for them. Um As we talked about the serious disorder is not to be missed. So that will definitely be um covered when you are covering your red flags and screening for them common pitfalls. Um and sort of some of the masque grades um ideally, you know, realistically in the OS station, they won't really throw this at you. Um It will be one of the sort of standard presentations um that you'd see and you'd be expected to offer see sort of expected differentials and that you would normally see in GP practice is a patient trying to tell me something else. So that was again, just mentioning on, make sure you're picking up on the patient's cues that they'll give you. And in an AK setting, they definitely will be quite, you know, if, if you're aware of sort of the fact that I do need to pick up the cues, you won't really miss them because once you miss, send the patient or the simulators, you'll find off and try and just add them in again somehow. So you do pick up on some of the things you need to, to be able to formulate some sort of management plan. So again, this slides taken from your assessment briefing, so I won't go through all of it. Um But just some of the things um that are on the mark scheme as well. So, um the second box, so specifically asking about relevant red flag symptoms and it depends on the presentation. So we'll see in the cases I won't quite spoiled the answers yet. But just for example, if someone's come in with very sort of gi or abdominal pain, you'd need to screen for like weight loss, fevers, um blood in stool, that sort of thing. So any sort of red flags relevant to the symptoms that they're presenting with, um, of course, you'll be assessed on your communication skills, consultation skills, addressing ice um empty sensitivity as with all stations, not just this one um and sort of the criteria for excellence in the station are really using your diagnostic reasoning skills to create a list of different tools. Now, it can be sort of, you know, another candidate might come up with a completely set of other different tools than you did. But if you're able to explain that to the patient and sort of give you a reasoning behind it, explain why you think that is and then offer the appropriate investigations. There's no reason why you'd lose marks compared to someone else. So in that way, the station offers that sort of flexibility that if you are sort of thinking broadly and keep it system based, then you're more likely to get in the range. Um And again, empathy and answer the questions that the patient has. Well, um they definitely will ask some of the questions, especially during the last five minutes when you're going through your investigations and management plan. And always remember that if you're not entirely sure how entirely sure of the answer, like if they ask you, how soon will the scan be or you know, when, when will the investigation happen? If you're not sure, you can just say just you ask senior or double check with the GP at the practice, don't sort of make it up if you're not aware of it. Um Because again, that will be one of the things they're testing you on because it comes under the professionalism. Ok. OK, so this is just sort of just going through um some of what we've already covered. So you're um assessed on your communication skills, um Patient safety. So that's relevant in the safety netting that you make sure you do that in your management plan. Um Duty of candor is we spoke about focus issue, taking communication, diagnostic reasoning. And I think I've already mentioned this, but so the station actually isn't necessarily about getting the correct diagnosis. It's just appearing comfortable dealing with the uncertainty. And if you've seen lots of patients in GP placements, you would have come across this idea. And most of the time, you know, the plan will be organized these investigations, safety net and then re review the patient to try and come up with an official diagnosis. So that's one of the key things that you're assessed on in this station. Um, and it is quite stretched for time compared to the other ones because you only have five minutes to take the history as opposed to a standard ten-minute history taking station. Ok. So this was the example lay out. So we'll go on to some cases now. Ok. So, um, you're a foundation doctor in a GP practice and you're about to see Mister Smith who's come in with breathlessness. So, um, in the first five minutes, if you take a focused history and then you, I'll tell you some examination findings and then if we suggest some differentials and management plans. So, if you guys are happy to type in the chat, what sort of things you would cover in your history? Um, for the symptom of breathlessness. Yeah. At rest or during exertion. Good. Anything else? Yeah, good. So, yeah, onset duration progressions. The onset is really important. Is it acute onset? Is it chronic, has it been going on for a while? Um, if it's acute onset you'd be more worried about a potential sort of acute cause of the symptom. Um, yeah, chest pain. Good. Good to, um, look at the red flags. Previous baseline. Yeah. So if they've had this, uh, sort of longstanding issue, then that could point to more chronic conditions, hemoptysis. Yeah, definitely. Yeah. Lying down P and D. Good. So you're thinking more sort of cardiovascular, we've got um, respiratory um, questions, fever, cough, cold. Yeah. Past medical history. Yeah. Good. So don't forget, just because you are taking a focused history doesn't mean you stick, don't stick to your sort of standard past medical history, drug history, allergies, family history, et cetera. Yeah. Good. Yeah, that's good. Calf pain. Yep. So screening for DVT is good for P ES exercise tolerance. Yeah. Yeah. Leg swelling. Ok. Good. So we've got a good range of suggestions. So we'll move on. Ok. So as I said, it is a focused history. Yes. Good. Yeah. Thank you. Ni so you asked for specific risk factors. Yeah. So, um, history of presenting complaints. So, the, in regards to the breathlessness, the onset duration, progression, aggravating and relieving factors associated symptoms, past medical surgical history, any regular medications they're taking. Um, so in this sort of case, for example, past medical history of like COPD or asthma or heart failure would put you along those lines, um, social history. So especially in the case of breathlessness, looking more at sort of their smoking, um, history, uh, but of course, you'll be guided by what sort of the patient is saying. So you do need to keep it relevant and think. So it might not necessarily be relevant in five minutes to cover their past surgical history, for instance, um if it's not really relevant to the symptom that they're presenting with and then someone mentioned the onset. So it's really, really useful to um assess the onset to narrow down your different. So, acute causes of shortness of breath might potentially be a pe or something more subacute or chronic, could be something like longstanding heart failure or COPD. And as we talked about, always, always screened for the three main red flags of fevers, night sweats and weight loss, um especially screening for any potential, for example, lung malignancies, um more relevant in this case. So as you are approaching the station, um if you do keep a more system based approach, it will really help when you are deciding on your investigations and your management plans as well. So if we split it into the main systems that can cause breathlessness. It will be essentially your heart, lungs or any other miscellaneous causes. So, cardiac arrhythmias. So I'm not quite, I don't know if palpitations were mentioned, but it's something really important to ask about. So for example, patients with af the initial presenting symptom might just be breathlessness, not necessarily the palpitations or a racing heart. So about arrhythmias, um pulmonary edema. So we mentioned heart failure could cause it. Um Mr S in rare cases. So we um someone also suggested chest pain which was good pulmonary causes. So, asthma, you could ask potentially about sort of atopic symptoms. So, hay fever or eczema that's sort of in in the past medical history, cop Ds. Um we mentioned cough shortness of breath. So fitting in with any potential pneumonias, chest infections. Um you guys also talked about risk factors for uh DVTs um to point towards potential pe and we did cover some of the red flags like hemoptysis uh as well. So, uh screen for the bee symptoms, um any changes in their weight, um any hemoptysis, fevers, drenching night sweats, et cetera. Um and also consider anything else that could potentially make a patient breathless. So if you try and think sort of outside your normal cardio respiratory system, so anemia can always make someone breathless. So sort of routine investigations in GP line would be getting an initial set of bloods, a full blood count. Um sort of CRP renal function, liver function, that sort of thing that you'd want to measure um more relevant sort of in the social history. So I remember in sort of one of the practice stations last year, um that one of the differentials we could have suggested was potential anxiety. So don't forget the importance of taking a good social history. So ask the patient um if there are any, if there's anything that could have potentially triggered this breathlessness or this change, especially if it's a chronic change um in their breathing, um any stressful life events, um because it just might be useful and they might just sort of throw in a queue that you, that you'd be expected to pick up on and some sort of rare causes like metabolic sort of DKA um thyroid disorders can um sometimes cause breathlessness as well, but it will depend on sort of the presenting symptom. So these were the patient's examination findings. So, um heart rate was normal BP, fairly normal sats 99% on air chest was clear. Abdomen is soft, nontender. A glucose was normal and they were apyrexic. So if I were to ask you, what sort of framework or suggestions would you have for the potential investigations or management plan, you'd offer this patient um bearing in mind, this is what you'd be told. So at this moment, the diagnosis isn't really clear. Um But how would you sort of go about explaining this to a patient. How would you structure it? Bedside bloods, imaging? Yeah, great. So that's how you'd so yeah, bedside bloods imaging and special tests is a really good framework. So you don't miss out the initial investigations, any other potential sort of any differentials, any um, investigations that you recommend. What's the respirate respirate was normal? It's about 15. Ok. That's ok. We can move on. We'll go through some of the potential structures we can use. So someone mentioned the bedside bloods, imaging special tests, which was really good. So if you try and structure it like that, you won't go wrong because um you know, all patients pretty much in this station, you would sort of like some bloods for um and some bedside investigations for. So, for instance, in this case, um it was sort of a vague breathlessness, um chronic. So if you're not quite sure what's going on, you'd want to investigate each of the systems individually. So if you are thinking of potential cardiac causes, for instance, so as I said, af or any arrhythmias could present with breathlessness, so you might consider doing an ECG in this case, um or potentially a 24 hour tape referral because the ECG wouldn't pick up on sort of any paroxysm more um rhythms if they have any, if the patient did have any chest pain or exertion or shortness of breath, sometimes what's often done in general practice is they're referred to the um a rapid access chest pain clinic, um, where sort of a history of their examinations done and then they can be usually referred for a CT Coronary Angio. Um, but again, in an OSK station, if you don't have time to say all of these things, you could list some cardiac investigations, like an ECG and a 24 hour tape would be good suggestions. Um, in this sort of case, um, if you're, if you're thinking of sort of pulmonary causes, so always a chest X ray and if they did have a cough or if they're bringing up anything, you can consider sputum cultures. Um And if you're considering, for example, if they have an excessive smoking history and their social sort of background, you might consider um doing peak flows and spirometry referrals and sort of to assess or if they have potential COPD. Um Yeah, bloods, as we mentioned. So anemia could cause breathlessness. So it will always be worth um of suggesting to the patient that we will do some initial blood tests to assess sort of h hemoglobin levels, liver function, renal function, um and checking the sort of inflammatory markers and potential other bloods depending on the presentation. And as usual in your plan really, really important to end with safety netting advice. So if they are experiencing, for example, chest pain, worsening, shortness of breath fevers, et cetera, then to seek medical attention, you can always um also useful um thing to add in into your management plan would be patient information leaflets and that will help sort of give you more marks in terms of sort of the continuity of care and that you're being more sort of patient centered. So you're offering them a chance to um read up about the condition. Um and what sort of diagnosis that you're thinking of? So always um useful to give some leaflets, just a question coming through. So, if you don't safety net, would they fail you on that station? Um It's hard to say if it will be sort of, you know, an immediate fail because they'll assess sort of the global picture. But, um, a safety netting, it would sort of be one of the main things to address, especially in a general practice focused management plan. Of course, it depends on the symptoms they're presenting with. Um, but uh, because of this uncertainty element, it's always good to safety net in any, um, GP consultation type setting. Um, it wouldn't necessarily be a fail. I don't think as long as you're offering, you know, a reasonable set of investigations and management, but I'd say for this station, if you try and remember to safety net, it will definitely, it will definitely look good um, on your part because you, you're sifting through sort of potential serious diagnoses. Um, that's important to do when someone presents with an uncertain type, uh type of symptom. Um Yeah, so not necessarily, you fail but try and try and remember to do that if you can. Does that make sense? Ok, great. No worries. Ok. So any questions about this case at all or how you sort of any investigations management, anything like that? Well, the observations were normal, not necessarily, no, not necessarily. Um in the observations can sort of all depend on the case, but because it will be, it is sort of a GP based uncertainty type setting. So it will be unlikely for them to give you someone who's like clearly septic, for instance, because then the management would be sending them to a and so it wouldn't necessarily lead you to sort of consider management in terms of biopsychosocial type thing. Um If that makes sense, so not necessarily normal, but um it would lead you to multiple diagnoses. Um not necessarily just an acute one, uh what came up for you guys. So this, this case of breathlessness um actually came up uh for, for my uh station for final station anyway. Um And this was a sort of logical approach. I had sort of system based and it really helped um that sort of guide the station because initially, it's because it's a focused history. Um If you go by your standard sort of history presenting complaint and all the sort of different topics that you need to cover, it can sometimes be difficult. But if you have a system based approach, you will be able to offer the investigations for that system and then appropriate plan. Um, so, yeah, uh, what a management plan that is going to be the appropriate. Yeah. Yeah. So I think that's covered this. So not necessarily because, um, it wouldn't necessarily fulfill the requirements of the station of being comfortable and explaining the uncertainty to the patient. Um, that being said it potentially could be, you never know what they'll throw at you, but I think it will be unlikely for them to be a more sort of more one of the symptoms that you do see in GP land and it won't be an acutely acutely unwell patient. Um, because all you'll say is just send them to A&E and it wouldn't necessarily be assessing any of your investigation or management plan skills. Ok. Ok. So if there's no other questions about that one, we'll move on to the next case. So again, you're in GP and you're about to see Miss Rogers who's now come in with fatigue. So another general vague symptom. So you'll be taking a history and then differentials and management. So we'll do a similar sort of thing. So what sort of questions would you want to ask in your focused history for fatigue? Red flags again? Yeah, good. So, really important in this case. Yeah. Yes, good. Yeah. These symptoms. Yeah. How long these symptoms of sleep? Yeah, very good. Um So sleep is one of the things um to address in your social history. Um So how are they coping any significant stresses in their life? Any anxiety, ask about their occupation? If it's relevant? It's really good. How long? So the onset? Yeah. Pains. Yeah. Good. So, if you're thinking along the lines of sort of maybe fibromyalgia or chronic fatigue type picture, which will be actually good. A good case for them to give you a neuros. Um because it's something sort of seen quite a lot in GP um onset mood, weight loss bleeding. Oh, excellent. Yeah, good. So lots of you're thinking of lots of different um causes of fatigue. Um So mood linking to potential site causes PV bleeding. Yep, some menorrhagia um could cause fatigue especially if it's um young woman if low mood safety net. Yeah, definitely. Yeah. So um if it is sort of if the case is pointing towards more psych causes um like depression, et cetera, definitely safety net. Assess risk as well. Enlarged lymph nodes. No, no lumps. Good. Yeah. So thinking of potential lymphomas um or any he malignancies. Great BMS. Yeah, diabetes definitely big cause of fatigue screen other psych conditions if relevant. Yeah. Yeah, definitely. So anxiety, you know, you ask a sort of a short sort of any if you say if you always stick with the in the social history, any significant sort of life events or anything, it should lead to the patient giving you some cues as to what they want you to get palpitations, shortness of breath on exertion. Yeah. Yeah. Cardiac arrhythmias can present with fatigue. Yeah, anemia, thyroid symptoms, thyroid. Great. Yeah. Yeah. So another key system, um, I was looking for was definitely endocrine. So, hypothyroidism being a big cause of, um, fatigue seen in general practice. So T FT S would almost always be done. Ok. Good. I think you guys have got a good range of suggestions again. So, a similar sort of thing. So keep it system based. Sorry about that. Um So yeah, so if you keep it um system based. So past medical history, history of presenting complaint, um drug history, allergies, if it's relevant um social history. So in this case, as we said, occupation, sleep, um smoking, alcohol exercise, um and life events. I think you guys covered a lot of these actually so good um cardiovascular. So someone mentioned palpitations, shortness of breath, um and exertion and because you are uh in GP so screening red flags, lymphomas, he malignancies, neuropsych, which I think you guys are all covered. So, metabolic was a big one I was looking for. Um So diabetes being a really common um cause of fatigue. So, um sort of the standard symp ask about standard symptoms of polyuria, polydipsia, any weight changes, any significant family history, um and hypothyroidism uh which we covered. So just some of the common symptoms of hypothyroidism that you could screen for and that will, it will look good to the examiner if you are doing this because they'll know that you're thinking through some of these differentials in your head. So sort of a sort of short systems review. So any weight gain, um, hair loss, dry skin constipation, menorrhagia, hypothyroidism can present with menorrhagia or menorrhagia can be an isolated cause of the fatigue. Um So especially if it's a woman. Um, that's one of the things to consider any gyne causes and their diet and lifestyle. So if they've got a really bad diet and if they have some nutritional deficiencies, for instance, they might be anemic and will most likely present with fatigue as well. So good. Um And in terms of the, I think I'll just go to like, yeah, so this, I got off the nice C KS um guidelines. Um and I'd recommend using this site when you're revising for this station actually because the C KS guidelines are primary care based. Um And if you filter it by sort of the presenting symptoms, it will give you some ideas on what sort of things could come up in this station. So shortness of breath fatigue, any vague symptoms like abdominal pain, it's sort of the sort of symptoms which would lead to an uncertain consultation where you are not quite sure what's going on and you would need to order some investigations to be able to come to a diagnosis. So, in this case, some of the recommendations they had were if someone was presenting with tiredness and fatigue, you can ask about the onset duration um impact on their activities and sleep pattern, which someone mentioned, which was good as we talked about life stresses. Um any psychosocial sort of comorbid depression, anxiety, any chronic conditions in the past medical history, if they do have sort of so many like fibromyalgia or any other chronic conditions that they're living with, that can always contribute to it and always just ask sort of, you know, are they sort of receiving follow up for that condition? Are they um um are they sort of under anyone or any consultant um managing those conditions? Um and C FS potentially you can screen for um if you want as well and always, always red flags, uh which I think you covered all of them with the lymphadenopathy, weight loss, fever, night sweats, which was really good just as a patient expand much on their complaint or expected to go through each system. Essentially. It depends on the uh Sim Simulator, to be honest, um they will, they know that there are only five minutes available for the history taking. So, um to be honest, they will give you sort of the information that you would need to come to some sort of diagnosis. Um And it's difficult because sometimes it will be like, oh, I just feel tired all the time and you'll be expected to pick up on that. What do you mean? How long has it been going on for? Um, but if they are being quite, you know, reluctant in giving you that information, if you go through each system essentially, or the main ones that could cause a symptom, um, you'll, you'll be able to get all the information you need within the five minutes. So it will be a good sort of, um, approach to s through the relevant information that you need. But they should, um, they won't dwell too much on the presenting complaint if that makes sense because they know you've only got five minutes to take a focused history. Is that, is that clear or do you need more expanding? Ok. Yeah. So in this case, that's all. Ok. No worries. So, um, in this case, so these are some of the examination findings. Um So BP is fairly normal heart rate, normal, regular chest, clear, abdo soft, no tender. Um, you assess for a goiter. Um, so which is not palpable. They're apyrexic, but there is some conjunctival pallor present and their hands are cold to touch. So, just based on this information, um, what sort of things would you be saying to the patient? What sort of investigations or differentials and management would you consider saying in the five minutes? FBC? Yep. Good to check for anemia. Yeah, like the anemia. Ok. Anything else T FT S? Yeah. Good. Anything you'd like to do bedside, if it's bedside bloods and special tests, anything bedside urine dip. Yeah. Good. Yeah. So sometimes sort of CKD. Um and chronic renal failure can present just with fatigue sometimes. And you know, m so the EGFR is sort of 15. So urine dip be very important to check for protein or blood. How old is the patient may need? Fit test said sorry. So is she um she's about 34. Um But yeah, it test is a good shout. You're again screening for um some of the red flags. No, it's a good, it's a good suggestion. So definitely someone older. Um you'd wanna screen for any sort of blood in stool, et cetera because any malignancy could always present with just fatigue. Um So good. Any other suggestions? Gynae? Yeah. Excellent. Yeah. So yeah, you can get a pelvic ultrasound if you're suspecting um heavy bleeding. Good. So we've covered some of the main symptoms. So we've covered metabolic thyroid anemia. Um I think uh so we should do sort of uh assess for diabetes as well. So it would be good to do an HBA1C or you can do ABM um at, at the GP as well. And the urine dip would show if there's any glucose in the urine as well. Ok. All right. So just conscious of time. So, ok, so again, organizing into the um bedside bloods, imaging special tests. So, bloods, um FBC is hematinic. So check your um B12 FOLATE TS and these so chronic liver failure or chronic renal failure because sometimes just present with fatigue and vague sort of symptoms. So always assess their baseline function, inflammatory markers, bone profile. So a bone profile and just sort of a hinter for your writtens as well is actually a separate blood test. So the calcium and magnesium isn't part of the normal urea electrolytes. So you need to request that separately. So it's another investigation, you could um potentially suggest hypercalcemia if you remember the classic symptoms of stones, bones, grown's etc. So it could present with fatigue and you can screen for other symptoms like constipation, bone pain, etc HBA1C, um lipids, thyroid function mentioned urine dip. So as we talked about aces of protein and blood in the urine and um you said the pelvic ultrasound as well, which was really good. So, in this sort of case with the symptom like fatigue, it obviously depends on um sort of what the patients told you, but some of the management plan suggestions um would sort of fit with a biopsychosocial approach. So, if there are any um red flags that they are displaying, for example, if the examiner tells you that they've got sort of palpable, non tender, lymphadenopathy, cervical or wherever it is. Um and the symptoms quite fit and that of malignancy, you might suggest potentially doing a secondary care referral. Um give them some leaflets. Um if relevant sleep hygiene advice, always um give them lifestyle advice. So you know what the point I'm trying to make is the management plan doesn't necessarily have to have all the medical investigations and you're not expected to offer them any specialist ones. Really. If you have a holistic approach and keep it by psychosocial and you'll get a lot, you'll score more highly than someone who is just going at it purely medically. So lifestyle advice in a presentation like fatigue. So rest periods, relaxation techniques offer them dietary advice. And if there are any psychosocial things you picked up in the social background, um talk about managing the stress. Um You can talk about referral to psych services or online CBT that sort of thing. So bringing your fourth year knowledge into this as well. Um And we mentioned screening for anxiety, depression and trying to manage that along those lines as well, which was good. So any questions at all about this case or how to go about? Um I think that's the last case or how to go about sort of the station or how to frame the um structure. I hope I've offered a useful structure to stick by. I think if you keep it system based, um you're more likely to pick up on the things that they want you to pick up on and keep it focused in the five minutes. But any questions at all, no worries, investigations to mention them in lay terms. Yes. Yeah. So, um you'll essentially sort of pretend you are in a gps um practice So if you're telling them, for example, I want a full blood count, tell them, you know, we'll do a blood test to measure the level of hemoglobin. Because if that's sometimes low, that can make you feel tired, we'll measure your kidney renal function, we'll measure your thyroid. Most people tend to know that um HP one C you can say is glucose and sort of scans and things. Um If you're referring them for, um you try and explain them as you would to a patient. So for example, if you are organizing a CT, for instance, or referring them on to secondary care for a CT, say we'll get a CT of your chest to see if there's anything, any sort of masses or anything that we are looking for. So essentially, because we are you, the whole station will just be communicating with the patient, not at all with the examiner. So you wouldn't need to, you, you can just talk to the patient. Ignore the examiner, essentially. No problem. OK? So I think that there's no other questions. I think I'm handing over to Beth for now for the next part. Anything to add NDI? No, I think that's been really good. Thank you so much for the, you can still put them there. Yeah, thank you. Thank you. Thanks. But if you want to just take control of the slides and unmute yourself, you can go ahead with the next bit. Well, I just take control now. Ok. Dokey. Is this working? Yeah. All righty. So if anyone wants a little quick break now, um then go ahead. So I'm just gonna go through what the station sort of the guidance is that we got given um before our um, so there's nothing that you guys won't have already. So if you want to take a little break, then feel free. So, my name is Bethany. Um So I'm an F one in Barnsley at the moment in South Yorkshire. And I'm gonna go through the multi morbidity and polypharmacy station of the. So this is all about basically like a medication review. So the station guidance, this is really tiny on my screen. So I'm struggling to read it, but you have 10 minutes for the station and you'll be given a hospital discharge letter which you can read in the two minutes before the station starts. So in your reading time and then it tells you that you need to take a brief history from your patient and then go through the patient's medications with them and make any appropriate changes and also negotiate with the patient as well about the changes that you are thinking of making. And then on the side of the um screen is what it says is that an excellent candidate would be able to do and I'm not going to read it all out. But if you do read it a lot of it is about your history taking skills and your rapport with the patient rather than what you decide to do with the medications. So even if medications are not your strong suit, you can still get pretty good marks in the station just by doing a really good history empathizing with the patient, doing a good ice and all that kind of blah, blah as well. Um, so don't panic too much. Cool. So that's basically the general layout of the of the stations. A discharge summary. I put it on the next slide. So you start with your discharge letter in your two minutes reading time, then you take a brief history from your patient and then you'll do the medication review and I'll talk about it a little bit more later, but it's good to get your eyes in the brief history because I'll inform your medication review as well. And that's very important. So with the discharge letter pretty straightforward, to be honest, there won't be huge amounts on there because um you only got three minutes to read it and make a little bit of a plan. So important things to pick out uh the reason for admission. So that's what the patient is struggling with the most at the moment, struggling enough for them to go into hospital to try and get it sorted out. And if it's a long term condition, which it might be because it's uh also multimorbidity stations, it might be a long term condition too. It indicates how well controlled that condition is. So, they've just been admitted for an infected diabetic foot. So, you know, that diabetes is not under great control and then information on this day. So, did they have any complications while they were in there? Um, also the severity of the problem as well? Were they just in for like half a day to sort something out or was it a prolonged stay? And did they get any new diagnoses when they were in as well? And there'll probably be a little recommendations for the GP uh section there too and highly likely that you will be acting as the GP in this. So that's a thing to take note of. And then, because it's a poly pharmacy station, any medication changes, um, any interaction and you can be thinking in your head at this point, are all these medications necessary? Are there any interactions that could be happening between any new meds and their old meds and any side effects as well that you know about or any sort of troublesome drugs that you're like? Oh, that's a bit dodge. I think I need to ask about that. And during my office I always made notes of these, um, because it will just completely leave my head as soon as I put the discharge letter down. So I just make a little note of these things. And then also in my two minutes of reading time, I would write down these headings. So just to, as a little checklist to go through just to make sure I didn't miss anything. So for your brief history, the presenting complaint or why it is that they went into hospital any past medical conditions and then drug history, you can, you, you will have it written down there anyway, that there are existing meds and any changes in anything. So, and you might have, you probably have the past medical history written down in front of you. So these things, you can kind of just skip over a little bit um or say if you've got a little history, you like your past medical history, you can say, oh, I've got it here, but you've got XYZ conditions, is that right? Or something like that? And then social history as well is quite important and then ice as well. So those two together will probably come in handy when you're doing your medication changes. And because it's an ay all patients will have some kind of hidden agenda. And so that gives an opportunity for the actor to tell you what their hidden agenda is quite early on in the station. And then you can use that to inform your medication review. And again, with the negotiating medication changes, if something very important to them, they might stand very firm and it's good to know why they might be thinking that way from your eyes and stuff. Course you've done those two things. It's difficult to say how long the history should take you. Um, probably only about 34 minutes or something. It, it, it depends on the patient's history. It's quite a straightforward history. Um, then obviously it'll be a bit shorter and you have more time for your medication review. But then sometimes it is worth putting in the effort and the time into that history so that you are better informed for your medication review. So it's up to you about what you find works for you. Basically, I think I only did like a three or four minutes or something and then that brings us on to the medication review. So the bits and italics are what it told you on your first on this slide in the red basically is what the italics are. So that's the things that they tell you that you should be doing. So discuss each of the patient's medications with them, including any indications and relevant side effects. If you're given a whole list of meds in my view, it's not worth going through every single one asking them if they have any side effects from them or do they know why they are taking it? I would use what you got from the ice. Like what the patient is most concerned about to inform which medications you start first. So for example, if they say, oh, they started me on um Ramipril in hospital ever since I left hospital, I've had this horrible dry cough. Then I would start with that one first rather than from the top. Um, and also with the medications, are they, are they compliant with the medications as well? So some meds have, um, specific instructions. So, like inhalers, for example, uh, they're taking their inhaler correctly. All that kind of stuff is, again, factors into discussing the patient's medications. And then you go on to just to suggest any appropriate changes to medications. So when you are reading time at the start, you might have noticed that a couple of meds interact and so then you can counsel the patient on, on that and discuss any changes and negotiate a plan with them and then that comes into the third bullet point. So negotiate and agree on, on an acceptable plan and then the whole thing should be patient centered as well. You're not the one taking the, the drugs they are. So it needs to be negotiated with them. That was quite speedy because I have got two cases that, which are fairly meaty. So, has anyone anyone got any questions on the layout of the station so far? The previous slide was that the brief history one? Cool. I will leave that up there for a few seconds to be able to take notes or photos or whatever. Yeah, it's a brief history. You'll get quite a lot of it in the discharge letter anyway. So it's up to you how much you want to be asking about what their past medical history is. If you practice it a few times with some friends, um, just go through the station, then you'll get a bit of a feel about what works for you. Really? And that's medication if, if anyone wants to. So always do a brief history first. Yeah, I am always do a brief history first because that is actually in the um station guidance. If I just flip you want that one. So it does say to take your past medical history, drug history, social history and all of that. Well, they move you on from history to med review. Um I mean, I would hope that your history wouldn't take long enough for them to feel like they have to move you on if that makes sense. So I would try and limit it to like 2 to 4 minutes or something because the bulk of, um, your marks will be from the medication review. Um It, I think it just depends on the examiner to be honest about whether they move you on or not. All kind that feeling. But if you're like 67 minutes and you still on your history, then I would get to move on. I don't know if that answers your question or not. But yeah, I would, I, if, if you practice this station with some friends one or two times then you, you'll get a bit of a feel about what works. And if you have the guidance in front of you, you'll see how many points that you checked off on the guidance to see how many, um points you've got. So if so if you're struggling to get to medication changes, then you might think, oh, II might need to cut some time out of this section or this section. Perfect. So I've just got a little slide here about some example, issues of um what might be wrong in their medications. So I've already already briefly mentioned interactions. Um So for example, nsaids and ace inhibitors, they um both have a little bit of nephrotoxic ness. Uh So for example, if on the discharge summary, it says that their um using these are a bit a bit dodge, then you might think about any interactions that might be causing that. Um blood thinners, nsaids and SSRI s or have bleeding risks associated with them. Um And then methotrexate and trimethoprim. If someone is on methotrexate, you shouldn't be prescribing trimethoprim, try metho because they are both folate andon and then a potassium sparing diuretics, both are pure potassium and there was obviously a whole host of interactions, side effects. Um There's just some listed there which are quite common. Um We can go on for ages about side effects. To be honest, I'm not sure how um how much you might know this already if you're revising for your uh PSA S and stuff. Um but then things that are contraindicated is quite important. So, nsaids without PPI, especially in older people that can cause gastric ulcers. Um, the contraceptive rules, um, like, I wouldn't know them off the top of my head, but it might be worth, you can always say something in your history if you're asking about, for example, compliance with the pill and they say sorry, excuse me. And, and they say they're taking it every other day, then it, that's not advisable really. Um any drugs that they're taking that uh if they have hepatic or renal impairment at the same time, you might, that might want a bit of a review. And then if there are any medication rules. So for example, um if a patient is on bisphosphonate, bisphosphonates after 3 to 5 years, um if they fit a certain criteria, they might be eligible for a bisphosphonate holiday. So um that comes from, there's evidence that just a patient being on bisphosphonates for ages doesn't have any more benefits than if they have a little like a little break of a few years and then go back and then reassess whether they need them again, I had some really good, nice guidelines on that. Actually, if you wanted to have a look. Um And then if there's any sort of disease specific guidelines, so if a patient is on clopidogrel and they had an mi like three years ago, is that clopidogrel still necessary? Because you only really need it for 12 months after an mi and then you, then it can be stopped and then things like be blockers and asthma and some of those examples are quite specific. Um, I wouldn't get too bogged down in them. So for example, if they had renal impairment and you weren't sure which ones, um, were contraindicated in renal impairment or need a dose adjustment or something like that. You can always just say something out loud to make the examiner aware. So say, oh, I can see that your kidney function isn't, it isn't um optimal. I can have a look at your meds or like discuss your, your medicines with the pharmacist to see if we need to make any changes or something like that or um, oh, you're on the, you're on the pill, you missed a few doses. I'll have a look at the guidelines. Do you have access? Oh, II think I remember there was a B NF in the station. Um, so I think I looked at it in the reading time and they told me I wasn't allowed to do that. So II II think that was the station. It might be worth just sending an email to, um, or having a look back through the slides or something just to double check. But I think you have access to a BNF. But don't quote me on that, please. I don't know if anyone else knows and they want to put in the chat as well. Can't remember. II II think you do. And then just the last bit, there is a correct use and implant and compliance. So, inhalers are using them correctly bisphosphonates. There are the rules where, um, you have to take it on an empty stomach and then sit upright, take it with a big glass of water and not eat anything afterwards. Are they doing all of that? Who knows? And then s overall as well as a little add on if you want to get extra marks. So if they're sick, they should stop their ace inhibitors or Metformin or something like that, um things that can affect kidneys mainly um or they should increase their steroids as well as they've been on steroids long term. Perfect. Uh I realize that's a lot of information. But does anyone have any questions? Can you go over the structure briefly? Is that the structure of the station again? So that was the structure of, of, of the station again? Yeah. So you have a two-minute reading time to look at the discharge letter. Oh Like your answer. Oh In the medication review. OK. So, so with, with the medication review, it very much depends on the scenario. So if I um go back, let, let, let me think of an example. So uh let me just take the NSAID and ace inhibitor first. So if I saw that on a patient's um meds or something, I would maybe ask them why they're on the NSAID or why they're on, on the ace inhibitors or something like that. Um, and then I know it very much depends. So, yeah. So, so maybe I would ask them why, if, why, why they were on both of those medications and then, so say they were on the NSAID and the ace inhibitor and they were on the NSAID for horrible osteoarthritis and it's the only thing that's ever worked for them. And they were on the ace inhibitor for hypertension. That isn't that bad. I might say, oh, well, both of those interact and they can cause your kidneys to be damaged. Um I would also have a look at the kidney function as well to see if that actually is a problem. Um And then I might negotiate with the patient to say, ok, so the ibuprofen is the thing that works really well for you. Um So maybe we'll try and change your ace inhibitor, but then if it was something reversed. So the Ibuprofen is just because they get a headache occasionally, but they just take the ibuprofen regularly. I would talk, I would try and counsel them about stopping the Ibuprofen. So it, it's difficult to answer how you would structure the station in that sense. It's very specific on the scenario. Um But if you make it patient centered, you're not gonna go too wrong, to be honest. OK. And there was a question about do we need a safety net in the station as well? If you're making any changes or adding any medications, then? Yes, you should. Safety net as you would in real life as well. Ok. So, examiner expectations, I think we've been through that. Really haven't we? Mostly I will just quickly speed you through to our cases because I realize I have talked to quite a lot already. Oh, I know we're not in cases yet. So, um, this is just a little slide about. Um, this OS station is very, very useful for future practice because over 70% of adverse drug reactions are completely avoidable and could have been picked up before they cause any problems or cause hospital admissions or anything like that. And even in, in hospital, when you're prescribing loads of meds, sometimes it just slips your mind about any interactions or contraindications and they still cause problems and cause prolonged hospital stays. So, as much as we may hate this topic, it is very useful and important in, um, the rest of your career basically. And I, you probably have, but you might not have heard about the stop start tool. Um, there's a little picture of it just on the side of that slide and it's a very useful tool about particularly in elderly people about when you should stop medications and what criteria you can stop medications based on and when you can start medications as well. Um, so that's really useful. Just have a little skim through before this station because it will give you a lot of ideas about, um, what might come up in the Os. And if you're, if you're making up scenarios for each other for practice OSK, that's a really good place to start to get some ideas. Yeah, stop start to is very good right now for the cases. So, case number one, we've got Angela Bard who is a 73 year old female. And so her discharge summary reads that Missus Bard was admitted on the 10th of January following an effective exacerbation of COPD. She received antibiotics and steroids and remained in the hospital for three days before being discharged home. Her BP was consistently low during admission eeg file is fine is fine GP to please review your medications and then you got a list of past medical history there and all of her drugs on the side as well. And none of those have been changed in her admission. Those are all just her regular meds. So is there anyone you can put it in the chat or you can turn your microphone on or whatever you fancy? Um But has anyone got any idea of where you might start with this station? So we're thinking about history. What kind of things might you ask? Or where might you start if you get any symptoms at the moment? Yeah. So when you ask that Angela will tell you that she's been, she was struggling at home for AAA good while with her COPD getting really breathless and then she suddenly got worse and she had a horrible fever. So her son took her to A&E, she's not quite feeling back to normal yet, but she's feeling a bit better than she was. Uh, she thinks that the infection just tipped her over the edge a little bit. Where are we? Yes. And, oh, sorry. II missed the one before. Start with the antihypertensive. Yes. You would want to be thinking about that. Um, when you come to a medication review section, um, if we think about the history first though, um, you could be asking her about her low BP, whether she's getting any symptoms of that. So she get dizzy or, um, any feelings that she might faint or anything like that. I her Yes. Love that phrasing as well. Um, so if you ask about her ideas, concerns and expectations, um, Angela says that she wants to be independent but she doesn't like being on so many medications and she's getting swollen ankles and she feels like they're slowing her down and she's scared she's going to fall drug allergies. Yes. That is a very good point. I did not put in my slides very good. We should always be asking about drug allergies. Anything else? It's not a huge amount more, to be honest, I was quite generous with my answer. Giving quick social history. Yes. Um, so she'll tell you that she, um, lives alone but her son lives nearby and she, um, loves going out to the shops and to go for coffee dates with her friends. But she feel like, feels like she can't go as much anymore because she's getting so breathless and that kind of ties into ice as well. Lovely. So, if we quickly move on to our medication review now, so we've already had um a little message about the antihypertensives. What are people thinking about the anti hypertensives? Yeah, he is stepping down. Is any suggestions on? Yes, her amLODIPine could be causing peripheral edema. So I did mention she's having swollen ankles which is slowing her down. Nice catch. Um So if we're gonna step down any of them, uh you probably start the, the amLODIPine because it's causing some side effects. So for if you wanna be thorough, you can ask about any side effects of the Ramipril. So you can ask if she's getting um uh any dry cough or anything, but you'll probably start the amLODIPine because she's getting symptoms. Oh, yeah. Good, good. Uh Thank you. So, compliance is she's taking too much. So you can ask about um how much of the amLODIPine is she taking? How much of the Ramipril is she taking? Because it might just be, she suddenly decided to take amLODIPine morning and night as well. So, yeah. Good, good thoughts there. Is there any other things that you can see or anything else you might want to think about, uh, with Angela Clopidogrel and a statin. Uh, uh, no, I don't think so. I think there are a lot of people on clopidogrel and statins because they break cardio ask about G, oh, yeah, GTN spray use. Yeah. If she's getting any angina symptoms, blood thinners. Yes. Anything that you can think about with blood thinners. Yes. So, she's on Aspirin, Apixaban and Clopidogrel platelet therapy after five years of an MRI. So yeah, Aspirin and Clopidogrel five years after an mi is not necessary that clopidogrel could be taken off. But because she's got af she was put on Apixaban and if you read the evidence, there is actually as far as I'm aware, there is no added benefit of being on Aspirin and Apixaban at the same time. So you can, so you might be able to get away with taking off Aspirin and Clopidogrel both at the same time. So it should just be on the Apixaban. I think I got that from the stop start rules. So if anyone in the hospital tells you differently, I got it from the stop start rules. But yeah. Very good. Very good Alendronate Weekly dosing. Yeah, you can ask if she'd rather have the Alendronate Weekly. So you can do 70 mg once a week instead. So you need to be on Aspirin one year after an M I, so after, as far as I'm aware after an MRI you have to be on dual antiplatelet therapies, aspirin and clopidogrel for 12 months. And then after those 12 months, you can take down the clopidogrel and just put her just, just have your patient on aspirin. But the reason Angela is different is because she's also on Apixaban as an anticoagulant for her. Af which means the aspirin is no longer necessary because the, the Apixaban is better than the aspirin. Basically that on blood thinners, you need a safety net. Uh What was your safety net for? If you get a safety net, you have to be quite specific. So for example, if you were stopping the, I don't know signs of pee or DVT, um not necessarily because both aspirin and clopidogrel are antiplatelets. So they work mostly on um thrombosis. Um That's not very useful arterial thrombosis to stabilize plaques in arteries. Whereas DVTs are venous thrombosis, which is when blood is um coagulated, not really via a platelet pathway. Um I'm not explaining this very well, but if you think about if someone has a DVT or a PE, the treatment for that is ap span, it's not clopidogrel. So actually you, is that good by explaining it, I'm not sure. Um OK, it does make sense. Basically, the way I think about it is the antiplatelets are more for arterial stuff and the anticoagulants are more for blood stasis, venous stuff. Would you need to stop either the salbutamol or bisoprolol. Um ah good point. So bisoprolol, do you know why bisoprolol is a bit dodge with um lungs? Lovely phrase of question now. Yeah. So it's because of asthma. So the bisoprolol is a beta two. OK. With beta anti antagonist. Yeah, bronchospasm. Um so the bisoprolol is a, is a beta antagonist so it can cause bronchospasm and that's the same sort of pathway that is in asthma. So the for example, this salbutamol will be is a beta, is a beta agonist. So that kind of opposite effects there. So if you've got someone that already has asthma, it's not a good idea to cause their bronchi to go into even more spasm because they're already a little bit spasmed. But COPD is a different um uh pathology really. And that, I mean, it gets a bit sticky, they already have a bit of asthma symptoms. But I like your thinking. So in your sy, you could ask about symptoms of asthma. So you could ask about whether their breathing gets worse with any allergens and the cold. If they have a history of asthma as well, they have like childhood asthma and stuff like that. And that might make you think about the bisoprolol, but you wouldn't stop either of them just based on the fact that she's on salbutamol. You, you want to get down to the root of why you're worried about that. And the root of that is the asthmatic side of things but no. Yeah, good thinking, good thinking. I actually didn't think about that in the, um, in my next slide, which I will run to the next slide now, which has some of the potential changes that you might be thinking about. A lot of them we've already talked about. So good job. Um Yes, my first point was actually COPD control. Um, so we were very much focused on drug stuff, very ci drug stuff, but sometimes it is good to take a little bit of a setback. And um Angela was saying about how she struggled with her breathing for a little while and then the, the infection has pushed her over the edge, but she was a bit breathless for months. Um So it might be that her COPD control is not great. So how many exacerbations is she having? Is she, is she still smoking? Perhaps if she's just 20 a day, then you might think about counseling her on cutting back. Um Is she, is it having any limitations on her daily life? So she said that she's not going out as much as she used to because of her breathlessness? Um And then a little bit about compliance. So does she use a spacer? What kind of technique does she have? Um And does she get a flu jab as well that, that kind of stuff and what you could do as a little shortcut in your s because you don't really have much time for these, um, uh, medication changes, if you could ask her a couple of those questions to, just to show off to the examiner that, you know what you're talking about. And then you can say something along the lines of, um, would you be happy for me to book you an appointment with our COPD nurse specialist or something to discuss your COPD in more depth? And then you might talk about stepping up her therapy. So what, what was she on at the moment? She was just on? So she's on double therapy. Maybe you might try to triple like a triple and uh therapy. Instead you might just show off the examiner. You know what that is? Um lovely. So low BP. Yeah. Yeah, we talked about that already. So whether you think about maybe stopping the amLODIPine because that's the one that's giving her side effects and then we talked about the blood thinners as well. And also she was, so we talked a little about the um Alendronate, whether you wanted to step down to a once a week day dosing or maybe as we, I alluded to earlier, the bisphosphonate holiday um might be worth reading up a little bit on that if you just have a spare five minutes. Lovely. So just a few learning point just to sum up from that case that it was, it was quite a meaty one. There's quite a lot going on there. Um But I would, um, have your history and your medication changes very much guided by the patient and make it very patient centered. Um, have a knowledge of guidelines where possible, but I wouldn't stress too much about that because it, it will come up on your final vision and stuff anyway. So you have it up there somewhere and you can always just allude to the fact that, you know, something is going on and then maybe you might refer to a specialist or something like that. So your COPD now specialist, you might mention that you might book an appointment and then lifestyle changes as well. So if she's a while, I'm a smoker, then you might advise her to stop. Which ones would you stop? Um So if I was doing the station, um because she mentioned, well, because it says in the discharge summary, low BP and she mentioned that her ankles are swollen. I would probably start with the BP stuff and try and negotiate with her which ones she would want to stop with that. Um What else would I do? Then I might do the blood thinners as well because it's on three different kinds of blood thinners. So I might try and step that out. II probably would just do what we talked about. To be honest. I think everyone had really good ideas. Um So yeah, try and get a couple of changes in if you can into your, um, your medication review Yeah, I wouldn't get too bogged down on which ones you definitely should or shouldn't be doing. As long as you've got a good rapport. You're a patient. You're making it patient centered. You've got all those fluffy bits that they talk about in the station. Guidance. Yeah. II don't, I don't think there's a fixed answer unless there's something like, really glaringly obvious that they don't want you to miss. I think as long as you've, you're generally safe, I think you'll be fine. Again. I don't know if that's very helpful or not very wishy washy, but I have seven minutes to run through the next one. So we're gonna go on to case two because this is David Y. He was admitted on the eighth of January with a fall and he has three rib fractures. He stayed in hospital for two days for pain management. But while he was in hospital, he was struggling with shortness of breath and they did a chest X ray which showed pulmonary edema. So his furosemide was increased and Dapagliflozin was added for his heart failure. So instead of going through a history and all of that, I'm just gonna tell you a little bit about his, his background about what brought him in so we can get into the meaty um medication stuff. So Mr Yong, um he struggles with um nocturia. He gets up to go to the bathroom a lot at night. Um He doesn't feel great on his feet at night and then he just, he can't remember what happened. He just fell and then he broke three ribs, ribs from that fall. Um, at the moment since discharge, um, he, uh has, you know, he's been struggling with, with, with, with his pain a fair amount. He's, he's on quite a lot of pain meds, but, you know, his rib fractures are very painful. Um, and, uh, he's been having some funny episodes where he doesn't feel quite right, but he has a digestive biscuit and he feels a bit better and I think that might have been most of what his history was. Uh Yeah, let's let's go with that. So put in the chart, what you can see from his medication that you might think about discussing with a bit mister Y that is a good point. I that is codeine 60. Let's pretend codeine 60. But if it was Cocodamol, that would be a problem. When does he take Glucozide? Maybe you shouldn't take it at night? You should be aware of hypos. So yeah, you picked up on the hypos and the dagla flows in with the Glucozide. So does anyone know why they added Dapagliflozin? Yeah. So yeah, good. So they added DAG flows in because this patient has heart failure and I what might have happened in the hospital is that they thought this heart failure was getting worse and so they added Dapagliflozin on but our patient is already on glipiZIDE. And so those two are having stacked effects and are giving our patient hypos. So what might we think about with this patient regarding that? Because he can't go on having hypos. It's not safe stepping down. Yeah. Which one do quick? Yeah, you probably go for the glycoside because the um DD Gliflozin um has effects with the heart failure. So we've said that um it uh yeah, because he has the cardiovascular history and heart failure, but it also helps with diabetes. The glipiZIDE just does the diabetes. So you probably want to just step down the glycoside. Cool. And for bonus points, is there any other counseling or any other plans? Follow up that you might think about with that? All right. So I'll get to the other ones later diabetic review. Yeah. So you might consider um asking him to take his blood sugars more frequently when he's at home or if he might not be compliant with that um safety netting um about hypos again and then booking for HBA1C depends on the patient really. But yeah, you might want to have a bit of a follow up plan for his diabetic review if you're messing around with his diabetes meds, but he has bacter his meds. So he's on Ibuprofen with no PPI good and the kidney function as well. So you, you might think about potentially stopping the Ib Ibuprofen or adding in A PP and this is where the negotiation with the patient comes in. So if you say, oh, we can stop your ibuprofen, he might be really against that because he's just broken three ribs and he's in a lot of pain and he doesn't want you messing around with his pain meds. So it might be that you negotiate by adding in a PPI instead, NSAID and ace inhibitor. Yes, good. So yeah, kidney function is a big thing. So I haven't actually mentioned the kidney function in the um discharge summary. So you might ask about whether he would want a um e booking in in the GP Lovely. Is there anything else that we're thinking of? Why is he on amitriptyline? Yes, good. So you can ask him why he's on amitriptyline and he might say, oh, I had a knee replacement five years ago. Um They put me on that for pain after my operation but I'm not in any pain now. Good. Yeah. Tolterodine frailty closing full. So Tolterodine has quite a high anticholinergic burden if we can remember that or it might be the first time hearing about that. So, yeah, anticholinergic burden. Um and Amitriptyline also does have an anticholinergic burden too. Uh If, if, especially if he's taking the, the amitriptyline at night, is that contributing to him feeling a bit funny when he's walking around at night? Lovely. So yeah, you guys have got the station down. What about his pain meds? The new meds that he was put on, bother my mistake in writing codeine, which should be codeine 60 Q Ds. Good. Yes. So the side effects of the opioids. So, he's on quite a lot of opioids there. So, is he getting any constipation? Um, and also that will worsen his urinary symptoms? Yeah. So does he need, um, like prescribing or something like that? And then, yeah, his arm off is put on as um regular, but p might suit him better, especially if maybe, um, you might be wanting to have the morphine as a little top up just before he has a shower or something like that or walk to the shops, something that might be causing more pain. Good. All righty. I'll put everyone out about misery and we will go on to the things that I thought about a lot of things we did talk about a well done team. There's a risk of going to the toilet at night. So, amitriptyline anticholinergic burden makes you drowsy, but unsteady. Same with tolterodine as well and he's having nocturia. So whether or not he has an underlying prostate issue, uh, might need some investigation as well. So you can maybe have a general comment of saying, um, we can book a separate appointment um, about your going to the toilet at night to explore that further or something like that just to show that you're thinking a bit more laterally as well. But yeah, good. Um, and then she was put on quite a one dose of furosemide of 80 mg twice a day. Um So one, how is he getting on with that? Because a lot of the time in hospital they might have fluid overload and then you jack up the frozen my dose and then when they leave hospital, they're still on that frozen dose. But actually they don't need that high anymore because they've got all the water off. Um And so they might be having dehydration a few weeks down the line after they've been discharged. It's good to just ask how, how, how they're feeling on that new furosemide dose and also tying with the nocturia that is beading. So he'll be having some fide before bed, which is just gonna make his nocturia worse. And then we've got the Gliclazide and Dapo together which is causing his hypo, maybe think about stepping down the glycoside and then having a follow up as well for his diabetes control. After that Ibuprofen without sight protection. We got that too and then opiate burden as well. So, um, because he's got rib fractures, you want to balance the scale about whether you want to have his pain very well controlled because you want him to be ventilating well enough that he doesn't get stodgy lungs and get some pneumonia. But then you don't want to be wing up his opioids too much and causing side effects like constipation and also opiates can cause falls as well. So you don't want him having any more falls. So that's where your, your negotiation comes in. He's also on codeine and oral. So whether or not he could be just rationalized just to one or um whether he does want to carry on taking both of them and then reduced frequency. So we talked about P RN morphine instead of Q DS and then laxatives, we also talked about too, what do we need the glucose levels before deciding to stop gliclazide. Um So if he's got quite a convincing history of having hypos because a known side effect of DAA and all the S two inhibitors and stuff, a known side effect of that is hypos. Um So if he describes it very well in that he feels a bit sticky and clammy and lightheaded and confused and then he feels better once he has a digestive, I would argue that um it will be more dangerous to send him home and ask him to do the blood glucose monitoring and then bring him back in for an appointment to review, then it would be just to stop the glipiZIDE and then review if that makes sense. So that's a bit of a weighing up the risk though. No good question. Oh So just a few learning points from this case just to pick out, so negotiate with the patient, taking their wishes into account. So it might be that you're assuming that your patient might be mad and adamant that they do not want to change any of their pain meds. They want to keep exactly how they are. So then you might negotiate, adding a PPI adding in laxatives rather than reducing the pain meds. If you see what I mean, it's a bit of a negotiation and then think about anticholinergic burden as well for your little superstar points. Um, and then think about the reasons for medication. So, um, well picked out the, the, the amitriptyline. Um Why is he on it? Uh You had a knee replacement five years ago and you no, no, no longer need it. So you might as well just take that off. That's doing him more harm than good at this point. Lovely. So, does anyone have any more questions for me? There was a message earlier on about if you have any things that you want to ask, but I haven't had time or think about later, then you can send an email and then it will come to me or the team, what resources you use to practice a station. Um The most useful thing that we did for the station is to come up with our own um medication list and feeding problems into that because when you're writing the, I mean, the same for all the stations, to be honest, when you're writing on um your own stations, you're doing the background reading for that station and then you're thinking about what the examiner is thinking about and you're doing all that kind of stuff and it's just useful and then you practice it with someone and you're critiquing how their performance is and all those things together are just really useful for a practice. So I talk about the stop start um uh tool, which has all the things about um when about interactions with drugs and stopping and starting and all that kind of stuff. So II actually used that tool when I was writing these um uh cases and then also if, if you just walk on to any wards or anything like that, open A&E just have a look at patients um medication list and you'll probably spot a couple of interactions or something like that. Um just in real life because it's so common people are adding drugs all the time. They're not necessarily thinking about all the issues that could go along with the added drug. Oh, wow. That was a long message that just came through. Oh, another structure. OK. Open question. Yeah. Good. Yeah, stop start. We can negotiate. Oh, that's a good one as well. Monitoring. Yeah. So if it, if it any patients on any diabetes, drugs or um you know, asthma hypertension, any of those sort of long term conditions ask when their last um checkup was, that's a good one. And condition specific problems as well. Diabetic feet. Yeah. Keep a patient center as while we checking understanding if they have any questions they're happy with the plan and then, yeah, follow up and safety netting is important. I don't actually write that in the slides, which is my bad. But yeah, follow up and safety netting is very good for the station as well. No tears. I don't think I've actually heard of that one before. What I really heard is that like another stop start thing? I think I've only had, I've, I've, I've only really had a stop start. But yeah, if no tears is good, then go ahead and use it. That's great. Anything that you can do to help prepare for the station. So last slide is just a few key takeaways, um which you've talked about all before. So number one is established patients concerns and wishes early in the consultation. So do your ice and then that will inform everything else that you do find out what the patient's main concern is. And then the first part of your medication review can be addressing that concern and then the patient will be quite happy. Number two is use the reading time to its full potential. So um I would write down in the key points, any interactions that jumped out of me that I might want to consider and didn't want to forget. Um And uh and another thing would be if you do see that a diabetic, for example, you can write down diabetes check throughout the monitoring thing. And that was mentioned just before and then number three is if you have time, um then you can review common treatment pathways. So things like um the COPD treatment pathway asthma hypertension, all that kind of stuff and the stop starter, which I haven't stopped going on about for this whole session. Yeah, I hope that was useful for everyone. So what is it? And then I might be handing over to go over the next session and all that kind of stuff. Yeah, that's me done. Oh, thank you. You, you guys are really good. Thank you very much for interacting on the chat and everything. That's very good. Yeah, it was a great. I was just gonna ask you. So if you guys fill in the feedback, you'll have instant access to all of the slides and the recordings. Um And then next week we will be doing um OK, you go back on the side, please. I forgot. Yeah. So we'll be doing handover and prioritization next week, same time. Uh And then there'll be a little bit of a gap because of PSA and tutor availability and it's most likely that towards the end of Feb. So probably third week of Feb, we will do the final session and then after that, we'll just do a revision and recap. We are on next week, same time. So if you guys have any further questions, feel free to ask. Otherwise we will round up, we will stay, we will stay around her for five minutes. Um, and then we'll have a meet in May. I see you guys next week. Yeah. Sure. I'll go and, uh, yeah, I go and find your feedback. One sec. Yeah. Try that.